Provider Demographics
NPI:1972709137
Name:DAVID FAGAN, MD
Entity Type:Organization
Organization Name:DAVID FAGAN, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRILL
Authorized Official - Suffix:
Authorized Official - Credentials:CPC
Authorized Official - Phone:603-747-2900
Mailing Address - Street 1:79 SWIFTWATER RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:WOODSVILLE
Mailing Address - State:NH
Mailing Address - Zip Code:03785-1447
Mailing Address - Country:US
Mailing Address - Phone:603-747-2900
Mailing Address - Fax:603-747-2992
Practice Address - Street 1:79 SWIFTWATER RD
Practice Address - Street 2:SUITE 2
Practice Address - City:WOODSVILLE
Practice Address - State:NH
Practice Address - Zip Code:03785-1447
Practice Address - Country:US
Practice Address - Phone:603-747-2900
Practice Address - Fax:603-747-2992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-25
Last Update Date:2008-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH8707207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH80002165Medicaid
VT2165Medicaid
VTFAGA18669OtherVT BC
RE8137Medicare PIN
NHF26771Medicare UPIN
303809Medicare ID - Type UnspecifiedRHC