Provider Demographics
NPI:1225171630
Name:EVERGREEN VALLEY MEDICAL, PC
Entity Type:Organization
Organization Name:EVERGREEN VALLEY MEDICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:FAGIEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:508-930-7659
Mailing Address - Street 1:PO BOX 511
Mailing Address - Street 2:
Mailing Address - City:WRENTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02093-0511
Mailing Address - Country:US
Mailing Address - Phone:508-930-7659
Mailing Address - Fax:
Practice Address - Street 1:170 TILTING ROCK RD
Practice Address - Street 2:
Practice Address - City:WRENTHAM
Practice Address - State:MA
Practice Address - Zip Code:02093-1358
Practice Address - Country:US
Practice Address - Phone:508-930-7659
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335V00000XSuppliersPortable X-ray and/or Other Portable Diagnostic Imaging Supplier