Healthcare Provider Details

I. General information

NPI: 1235495458
Provider Name (Legal Business Name): NATHAN MICHAEL FAGAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2012
Last Update Date: 05/19/2022
Certification Date: 05/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 CHILDRENS DR
COLUMBUS OH
43205-2664
US

IV. Provider business mailing address

700 CHILDRENS DR
COLUMBUS OH
43205-2664
US

V. Phone/Fax

Practice location:
  • Phone: 614-722-6200
  • Fax:
Mailing address:
  • Phone: 614-722-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35133506
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number35.133506
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: