Provider Demographics
NPI:1780112078
Name:FAGER, SAMUEL SHAW (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:SHAW
Last Name:FAGER
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:PO BOX 369
Mailing Address - Street 2:
Mailing Address - City:VILLANOVA
Mailing Address - State:PA
Mailing Address - Zip Code:19085-0369
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1415 OLD GULPH RD
Practice Address - Street 2:
Practice Address - City:VILLANOVA
Practice Address - State:PA
Practice Address - Zip Code:19085-2041
Practice Address - Country:US
Practice Address - Phone:610-520-0246
Practice Address - Fax:610-525-3737
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT028579208000000X
CAG37093208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics