Healthcare Provider Details

I. General information

NPI: 1750315958
Provider Name (Legal Business Name): TIMOTHY D FAGEN D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 08/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1402 S GRAND BLVD STE M260 ST LOUIS UNIVERSITY GME
SAINT LOUIS MO
63104-1004
US

IV. Provider business mailing address

1402 S GRAND BLVD STE M260 ST LOUIS UNIVERSITY GME
SAINT LOUIS MO
63104-1004
US

V. Phone/Fax

Practice location:
  • Phone: 314-577-8782
  • Fax:
Mailing address:
  • Phone: 314-577-8782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number5101017047
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberDOS 1120
License Number StateHI
# 3
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number2010014000
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: