Provider Demographics
NPI:1134280142
Name:RONALD C FAGAN MD PC
Entity Type:Organization
Organization Name:RONALD C FAGAN MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:NICOSIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-752-7000
Mailing Address - Street 1:1111 BROADHOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735-4820
Mailing Address - Country:US
Mailing Address - Phone:631-752-7000
Mailing Address - Fax:631-752-7025
Practice Address - Street 1:254-41 HORACE HARDING EXPWY
Practice Address - Street 2:
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362
Practice Address - Country:US
Practice Address - Phone:718-224-4100
Practice Address - Fax:718-224-4527
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY227578207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0279P1Medicare ID - Type Unspecified
NYI01284Medicare UPIN