Provider Demographics
NPI:1831280494
Name:FAGAN, BRIAN MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:MICHAEL
Last Name:FAGAN
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 1:836 FORNHAM LN
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187
Mailing Address - Country:US
Mailing Address - Phone:630-681-9927
Mailing Address - Fax:
Practice Address - Street 1:JOLIET RADIOLOGICAL SERVICES CORP PROVENA ST. JOESPH ME
Practice Address - Street 2:333 N MADISON ST
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435
Practice Address - Country:US
Practice Address - Phone:815-741-7213
Practice Address - Fax:815-741-7591
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL361078172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology