Healthcare Provider Details

I. General information

NPI: 1710374996
Provider Name (Legal Business Name): THEODORE FAGRELIUS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2015
Last Update Date: 03/08/2021
Certification Date: 03/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1830 E MONUMENT ST STE 6-100
BALTIMORE MD
21287-0020
US

IV. Provider business mailing address

2120 L ST NW STE 450
WASHINGTON DC
20037-1541
US

V. Phone/Fax

Practice location:
  • Phone: 410-955-5107
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD467783
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberD85894
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: