Healthcare Provider Details

I. General information

NPI: 1528005543
Provider Name (Legal Business Name): KATHLEEN M FAGAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 06/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11100 EUCLID AVENUE
CLEVELAND OH
44106
US

IV. Provider business mailing address

3605 WARRENSVILLE CTR RD MSC9152
SHAKER HTS OH
44122
US

V. Phone/Fax

Practice location:
  • Phone: 216-844-7700
  • Fax: 216-286-6299
Mailing address:
  • Phone: 216-286-6299
  • Fax: 216-286-6341

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0500X
TaxonomyPreventive Medicine/Occupational Environmental Medicine Physician
License Number35051175
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: