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General NPI Number Information
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NPI Number | 1497877963
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Entity Type | Organization
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Legal Business Name | DONALD L FAGERSON MD SC
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Dates
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Enumeration Date | 04/04/2007
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Last Update Date | 04/23/2015
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Provider Practice Location Address
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Address Line | 1644 W COLONIAL PKWY
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City | INVERNESS
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State | IL
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Zip | 60067-1207
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Country | US
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Telephone | 847-358-1588
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Fax | 847-358-1542
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Provider Business Mailing Address
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Address Line | 1644 W COLONIAL PKWY
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City | INVERNESS
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State | IL
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Zip | 60067-1207
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Country | US
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Telephone | 847-358-1588
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Fax | 847-358-1542
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. DONALD L FAGERSON
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Credential | MD
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Telephone | 847-358-1588
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2084P0800X
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Taxonomy Name | Psychiatry Physician
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License Number | 036-085741
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License Number State | IL
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