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General NPI Number Information
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NPI Number | 1780112078
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Entity Type | Individual
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Provider Name | SAMUEL SHAW FAGER MD
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Gender | Male
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Dates
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Enumeration Date | 05/31/2017
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Last Update Date | 05/31/2017
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Provider Practice Location Address
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Address Line | 1415 OLD GULPH RD
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City | VILLANOVA
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State | PA
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Zip | 19085-2041
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Country | US
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Telephone | 610-520-0246
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Fax | 610-525-3737
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Provider Business Mailing Address
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Address Line | PO BOX 369
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City | VILLANOVA
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State | PA
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Zip | 19085-0369
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 028579
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | G37093
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License Number State | CA
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