Provider Demographics
NPI:1164772026
Name:JUSTIN R FAGAN DC, PC
Entity Type:Organization
Organization Name:JUSTIN R FAGAN DC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SHAW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:212-751-8300
Mailing Address - Street 1:133 E 58TH ST
Mailing Address - Street 2:15TH FLOOR
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-1236
Mailing Address - Country:US
Mailing Address - Phone:212-751-8300
Mailing Address - Fax:
Practice Address - Street 1:133 E 58TH ST
Practice Address - Street 2:15TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-1236
Practice Address - Country:US
Practice Address - Phone:212-751-8300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008283-1111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX94732Medicare UPIN