Healthcare Provider Details

I. General information

NPI: 1477892909
Provider Name (Legal Business Name): FREDRIC IRA FAGELMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/04/2013
Last Update Date: 02/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13 ORCHARD DR
QUEENSBURY NY
12804-1307
US

IV. Provider business mailing address

13 ORCHARD DR
QUEENSBURY NY
12804-1307
US

V. Phone/Fax

Practice location:
  • Phone: 518-792-6983
  • Fax:
Mailing address:
  • Phone: 518-792-6983
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number122981-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: