Healthcare Provider Details

I. General information

NPI: 1669683405
Provider Name (Legal Business Name): BRYAN CHRISTOPHER FAGAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 01/26/2023
Certification Date: 12/09/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

499 GLOSTER CREEK VLG STE G1
TUPELO MS
38801-4751
US

IV. Provider business mailing address

499 GLOSTER CREEK VLG STE G1
TUPELO MS
38801-4751
US

V. Phone/Fax

Practice location:
  • Phone: 662-377-2663
  • Fax: 662-377-6706
Mailing address:
  • Phone: 662-377-2663
  • Fax: 662-377-6706

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberAU5009697-756
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number20606
License Number StateMS
# 3
Primary TaxonomyN
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number20606
License Number StateMS
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number20606
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: