Basic Information
| Provider Information | |||||||||
| NPI: | 1588689236 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FAGAN ER MEDICAL GROUP INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 N CENTRAL AVE | ||||||||
| Address2: | SUITE 750 | ||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912031926 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185570135 | ||||||||
| FaxNumber: | 8185571394 | ||||||||
| Practice Location | |||||||||
| Address1: | 1225 WILSHIRE BOULEVARD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900172395 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2134822741 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/13/2006 | ||||||||
| LastUpdateDate: | 12/13/2010 | ||||||||
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| AuthorizedOfficialLastName: | FAGAN | ||||||||
| AuthorizedOfficialFirstName: | PHILIP | ||||||||
| AuthorizedOfficialMiddleName: | J. | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 8185570135 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | CC6682 | 01 | CA | GOOD SAM RAILROAD | OTHER | GR0048650 | 05 | CA | MEDICAID | ZZZ43319Z | 01 | CA | GOOD SAM BLUE SHIELD | OTHER |