| Doctor Name: | TIMOTHY D FAGEN |
| NPI Number: | 1750315958 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | D.O. |
| License Number: | 5101017047 |
| Business Practice Address: | 1402 S Grand Blvd Ste M260 St Louis University Gme Saint Louis, MO - 631041004 |
| Business Phone Number: | 3145778782 |
| Business Fax Number: | |
| Mailing Address: | 1402 S Grand Blvd Ste M260, St Louis University Gme SAINT LOUIS |
| State: | MO |
| Postal Code: | 631041004 |
| Phone Number: | 3145778782 |
| Fax Number: | |
| NPI Enumeration Date: | 07/11/2006 |
| NPI Last Update Date: | 08/11/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | 5101017047 |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | MI |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |