Provider Demographics
NPI:1790812352
Name:FAGAN, THOMAS A (DC)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:A
Last Name:FAGAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 DORCHESTER ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02127-2228
Mailing Address - Country:US
Mailing Address - Phone:617-464-2227
Mailing Address - Fax:617-268-4218
Practice Address - Street 1:75 DORCHESTER ST
Practice Address - Street 2:
Practice Address - City:SOUTH BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02127-2228
Practice Address - Country:US
Practice Address - Phone:617-464-2227
Practice Address - Fax:617-268-4218
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2284111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA352504OtherHARVARD PILGRIM HEALTH
MAY36717OtherBLUE CROSS BLUE SHIELD
U77481Medicare UPIN
FAY45273Medicare ID - Type Unspecified