Healthcare Provider Details

I. General information

NPI: 1780112078
Provider Name (Legal Business Name): SAMUEL SHAW FAGER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 05/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 OLD GULPH RD
VILLANOVA PA
19085-2041
US

IV. Provider business mailing address

PO BOX 369
VILLANOVA PA
19085-0369
US

V. Phone/Fax

Practice location:
  • Phone: 610-520-0246
  • Fax: 610-525-3737
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number028579
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG37093
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: