Healthcare Provider Details

I. General information

NPI: 1518827419
Provider Name (Legal Business Name): ALEXANDER FAGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2025
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 MICHIGAN ST NE
GRAND RAPIDS MI
49503-3300
US

IV. Provider business mailing address

308 WESTOWN DR NW APT 308
GRAND RAPIDS MI
49534-3727
US

V. Phone/Fax

Practice location:
  • Phone: 616-331-5000
  • Fax:
Mailing address:
  • Phone: 616-502-3276
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: