Basic Information
| Provider Information | |||||||||
| NPI: | 1568789279 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FANELLI | ||||||||
| FirstName: | MATTHEW | ||||||||
| MiddleName: | JOSEPH | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 801 YORK ST | ||||||||
| Address2: | |||||||||
| City: | MANITOWOC | ||||||||
| State: | WI | ||||||||
| PostalCode: | 542204630 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9206639008 | ||||||||
| FaxNumber: | 9206841439 | ||||||||
| Practice Location | |||||||||
| Address1: | 66 PARKWAY LN STE 101A | ||||||||
| Address2: | |||||||||
| City: | FISHERSVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 229392385 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5404512833 | ||||||||
| FaxNumber: | 5404512837 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2010 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 71653-20 | WI | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 036.137205 | IL | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 51923 | SC | N | Allopathic & Osteopathic Physicians | Dermatology | 207N00000X | 0101276020 | VA | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.