Healthcare Provider Details

I. General information

NPI: 1831179373
Provider Name (Legal Business Name): MARTHA E FAGAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 05/13/2021
Certification Date: 05/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 REID PARKWAY SUITE 220
RICHMOND IN
47374-1156
US

IV. Provider business mailing address

1050 REID PARKWAY SUITE 220
RICHMOND IN
47374-1156
US

V. Phone/Fax

Practice location:
  • Phone: 765-962-9541
  • Fax: 765-966-5952
Mailing address:
  • Phone: 765-962-9541
  • Fax: 765-966-5952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01066632A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number0101233798
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: