Individual
JERRY FENWICK
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
771 N SUMMERCREEK CT, SPRINGFIELD, MO 65802-7249
(417) 771-4548
Mailing address
771 N SUMMERCREEK CT, SPRINGFIELD, MO 65802-7249
(417) 714-4548
Taxonomy
Speciality
Code
Description
License number
State
207P00000X
Emergency Medicine Physician
Primary
110179
MO
207P00000X
Emergency Medicine Physician
18407
SC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1366477549
—
MO
05
—
208524116
—
MO
05
—
G38753
—
SC
Enumeration date
07/12/2006
Last updated
01/20/2021
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