Healthcare Provider Details

I. General information

NPI: 1174133292
Provider Name (Legal Business Name): THOMAS FAGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2020
Last Update Date: 08/18/2025
Certification Date: 08/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2689
US

IV. Provider business mailing address

2799 W GRAND BLVD
DETROIT MI
48202-2689
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-1553
  • Fax:
Mailing address:
  • Phone: 313-916-1553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number4301511262
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: