Provider Demographics
NPI:1033200167
Name:FAGAN, KIMBERLY M (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:M
Last Name:FAGAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3125 INDEPENDENCE DR
Mailing Address - Street 2:SUITE 300A
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-4159
Mailing Address - Country:US
Mailing Address - Phone:205-879-8206
Mailing Address - Fax:205-271-3075
Practice Address - Street 1:3125 INDEPENDENCE DR
Practice Address - Street 2:SUITE 300A
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-4159
Practice Address - Country:US
Practice Address - Phone:205-879-8206
Practice Address - Fax:205-271-3075
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2016-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14105174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALI621OtherMEDICARE ID NUMBER
ALC73789Medicare UPIN