Healthcare Provider Details

I. General information

NPI: 1962449686
Provider Name (Legal Business Name): MARK J FAGAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 09/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST APC 5
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

17 VIRGINIA AVE SUITE 107
PROVIDENCE RI
02905-4406
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-4741
  • Fax: 401-444-4445
Mailing address:
  • Phone: 401-443-4992
  • Fax: 401-784-4902

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD05975
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: