Healthcare Provider Details

I. General information

NPI: 1750744843
Provider Name (Legal Business Name): ALEXANDER MAX FAGENSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/05/2016
Last Update Date: 06/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3401 N BROAD ST
PHILADELPHIA PA
19140-5103
US

IV. Provider business mailing address

3401 N BROAD ST
PHILADELPHIA PA
19140-5103
US

V. Phone/Fax

Practice location:
  • Phone: 215-707-2000
  • Fax:
Mailing address:
  • Phone: 215-707-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number211111
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: