Provider Demographics
NPI:1023146198
Name:RONALD C FAGAN MD, PC
Entity type:Organization
Organization Name:RONALD C FAGAN MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER /PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:C
Authorized Official - Last Name:FAGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-224-4100
Mailing Address - Street 1:4900 HEMPSTEAD TPKE
Mailing Address - Street 2:
Mailing Address - City:FARMINGDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11735
Mailing Address - Country:US
Mailing Address - Phone:516-752-7000
Mailing Address - Fax:516-586-8644
Practice Address - Street 1:4900 HEMPSTEAD TPKE
Practice Address - Street 2:
Practice Address - City:FARMINGDALE
Practice Address - State:NY
Practice Address - Zip Code:11735
Practice Address - Country:US
Practice Address - Phone:516-752-7000
Practice Address - Fax:516-586-8644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-01
Last Update Date:2015-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178331174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW86971Medicare ID - Type UnspecifiedGROUP #