Provider Demographics
NPI:1245359041
Name:FRAGEN, MICHAEL PHILLIP (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:PHILLIP
Last Name:FRAGEN
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 1:1615 S NORBURY AVE
Mailing Address - Street 2:
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-6182
Mailing Address - Country:US
Mailing Address - Phone:630-627-2511
Mailing Address - Fax:847-510-0505
Practice Address - Street 1:1615 S NORBURY AVE
Practice Address - Street 2:
Practice Address - City:LOMBARD
Practice Address - State:IL
Practice Address - Zip Code:60148-6182
Practice Address - Country:US
Practice Address - Phone:630-627-2511
Practice Address - Fax:847-510-0505
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207RS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RS0010XAllopathic & Osteopathic PhysiciansInternal MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BF3399739OtherDEA
ILF60647Medicare UPIN