Provider Demographics
NPI:1770740482
Name:FAGAN LLC
Entity type:Organization
Organization Name:FAGAN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLY
Authorized Official - Middle Name:M
Authorized Official - Last Name:FAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-879-8206
Mailing Address - Street 1:3125 INDEPENDENCE DR
Mailing Address - Street 2:SUITE 300A
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-4159
Mailing Address - Country:US
Mailing Address - Phone:205-879-8206
Mailing Address - Fax:205-879-0675
Practice Address - Street 1:3125 INDEPENDENCE DR
Practice Address - Street 2:SUITE 300A
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35209-4159
Practice Address - Country:US
Practice Address - Phone:205-879-8206
Practice Address - Fax:205-879-0675
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL14105335E00000X, 332B00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALI621OtherMEDICARE GROUP IDENTIFIER
ALI621OtherMEDICARE GROUP IDENTIFIER