Provider Demographics
NPI:1427061068
Name:FAGAN, KEVIN J (MD)
Entity type:Individual
Prefix:DR
First Name:KEVIN
Middle Name:J
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 1:27702 NETWORK PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-1277
Mailing Address - Country:US
Mailing Address - Phone:708-862-7674
Mailing Address - Fax:708-862-1781
Practice Address - Street 1:71 W 156TH ST
Practice Address - Street 2:SUITE 308
Practice Address - City:HARVEY
Practice Address - State:IL
Practice Address - Zip Code:60426-4260
Practice Address - Country:US
Practice Address - Phone:708-331-6617
Practice Address - Fax:708-331-7957
Is Sole Proprietor?:No
Enumeration Date:2006-08-14
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360687212084N0400X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400415105OtherMEDICARE
IL036068721Medicaid
ILP11828Medicare PIN