Healthcare Provider Details

I. General information

NPI: 1861982050
Provider Name (Legal Business Name): THOMAS MICHAEL FAGAN DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2018
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 GERMANTOWN AVE
PHILADELPHIA PA
19144-2225
US

IV. Provider business mailing address

5555 GERMANTOWN AVE
PHILADELPHIA PA
19144-2225
US

V. Phone/Fax

Practice location:
  • Phone: 215-991-9006
  • Fax: 215-991-9046
Mailing address:
  • Phone: 215-991-9006
  • Fax: 215-991-9046

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberDC006745L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: