Michael Niel Fenner, MD

Primary specialty

Surgery PhysicianTaxonomy code 208600000X

License

036080188 Issued in IL

Practice address

1600 W Walnut St
Jacksonville, IL 62650-1136

Phone

(217) 528-7541

NPI assigned

Sep 20, 2006

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Other identifiers 2

Electronic endpoints 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1158710400000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1612396800000",
    "number": "1578660445",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1025 S 6TH ST",
            "city": "SPRINGFIELD",
            "state": "IL",
            "postal_code": "627032403",
            "telephone_number": "217-528-7541"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1600 W WALNUT ST",
            "city": "JACKSONVILLE",
            "state": "IL",
            "postal_code": "626501136",
            "telephone_number": "217-528-7541"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FENNER",
        "first_name": "MICHAEL",
        "middle_name": "NIEL",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-09-20",
        "last_updated": "2021-02-04",
        "certification_date": "2021-02-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "AK",
            "license": "5616",
            "primary": false
        },
        {
            "code": "208600000X",
            "taxonomy_group": "",
            "desc": "Surgery",
            "state": "IL",
            "license": "036080188",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "R01571",
            "state": "IL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "MD3077",
            "state": "AK"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "michaelfenner@sfc.allscriptsdirect.net",
            "affiliation": "N",
            "address_1": "1600 W Walnut St",
            "city": "Jacksonville",
            "state": "IL",
            "country_code": "US",
            "postal_code": "626501136",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "mfenner1166073@ak.providencedirect.org",
            "affiliation": "N",
            "address_1": "1915 E Rezanof Dr",
            "city": "Kodiak",
            "state": "AK",
            "country_code": "US",
            "postal_code": "996156602",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Empowerme Rehabilitation Il Agency, LLC
• Valerie Ernst, PT
• Ryan D. Farris, AUD
• Lori Ann Feezor-Ribble, O.D.
• Agnes A. Fenner
• Lisa Marie Fernandes, LPN
• Tracy Leann Flanagan
• Jeffrey W Fleischli, DPM
• Rebecca Ann Fletcher, LCSW, CADC
• Jennifer G Flinn, FNP

• Surgery Physician in Jacksonville, IL
• Providers in Jacksonville, IL by specialty
• Surgery Physician in Illinois

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 4, 2021; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.