Provider Demographics
NPI:1659352763
Name:FAGERLIE, SETH ALFRED (MD)
Entity Type:Individual
Prefix:DR
First Name:SETH
Middle Name:ALFRED
Last Name:FAGERLIE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26078 N 71ST DR
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-7318
Mailing Address - Country:US
Mailing Address - Phone:623-362-3733
Mailing Address - Fax:
Practice Address - Street 1:5102 W CAMPBELL AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85031-1703
Practice Address - Country:US
Practice Address - Phone:623-848-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-07
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33539207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ39-81220OtherEVERCARE GROUP
AZAZ0728670OtherBLUE CROSS/BLUE SHIELD GR
AZAW1436OtherHEALTHNET GROUP
AZ936239Medicaid
AZAZ0728670OtherBLUE CROSS/BLUE SHIELD GR
I27375Medicare UPIN