Healthcare Provider Details

I. General information

NPI: 1881634210
Provider Name (Legal Business Name): BRIAN D FAGAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 08/06/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

373 W 101ST TER SUITE 210
KANSAS CITY MO
64114-4408
US

IV. Provider business mailing address

373 W 101ST TER SUITE 210
KANSAS CITY MO
64114-4408
US

V. Phone/Fax

Practice location:
  • Phone: 816-333-9500
  • Fax: 816-363-3700
Mailing address:
  • Phone: 816-333-9500
  • Fax: 816-363-3700

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberR3M20
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: