Basic Information
| Provider Information | |||||||||
| NPI: | 1912911991 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FENNEWALD | ||||||||
| FirstName: | PAMELA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 731 S ILLINOIS ROUTE 21 | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600313813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475663337 | ||||||||
| FaxNumber: | 8478163166 | ||||||||
| Practice Location | |||||||||
| Address1: | 731 S ILLINOIS ROUTE 21 | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | GURNEE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600313813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8475663337 | ||||||||
| FaxNumber: | 8478163166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2006 | ||||||||
| LastUpdateDate: | 08/26/2008 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0300X | 036057870 | IL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 036057870 | 05 | IL | MEDICAID | 04930281 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER |