Individual
MICHAEL NIEL FENNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1600 W WALNUT ST, JACKSONVILLE, IL 62650-1136
(217) 528-7541
Mailing address
1025 S 6TH ST, SPRINGFIELD, IL 62703-2403
(217) 528-7541
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
036080188
IL
208600000X
Surgery Physician
5616
AK
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
MD3077
—
AK
01
—
R01571
MEDICARE PTAN
IL
Enumeration date
09/20/2006
Last updated
02/04/2021
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