Healthcare Provider Details

I. General information

NPI: 1720189012
Provider Name (Legal Business Name): ROGER FAGAN AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JAMES ROGER FAGAN AUD

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

985 FOREST AVENUE
PORTLAND ME
04103
US

IV. Provider business mailing address

985 FOREST AVENUE
PORTLAND ME
04103
US

V. Phone/Fax

Practice location:
  • Phone: 207-797-8738
  • Fax: 207-797-8650
Mailing address:
  • Phone: 207-797-8738
  • Fax: 207-797-8650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberDL95
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAP25
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: