Provider Demographics
NPI:1811427636
Name:FAGG, JOHNATHAN SCHNEE (MD)
Entity type:Individual
Prefix:
First Name:JOHNATHAN
Middle Name:SCHNEE
Last Name:FAGG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 19627
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9627
Mailing Address - Country:US
Mailing Address - Phone:217-545-8000
Mailing Address - Fax:217-545-4734
Practice Address - Street 1:621 S NEW BALLAS RD STE 228A
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8256
Practice Address - Country:US
Practice Address - Phone:314-251-4968
Practice Address - Fax:217-545-4734
Is Sole Proprietor?:No
Enumeration Date:2017-06-14
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036153001207RP1001X
MO2023032929207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease