MEDICARE: MICHAEL L FESSENDEN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	2003016360	MO
2	207Q00000X	Family Medicine Physician	36118835	IL
3	207Q00000X	Family Medicine Physician	D66365	MD
4	207Q00000X	Family Medicine Physician	43269-020	WI
5	207Q00000X	Family Medicine Physician	8219	ND

General Provider Information

NPI Number	:	1023013638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHAEL L FESSENDEN M.D.

Provider Business Mailing Address
First Line	:	2003 W FULTON ST
Second Line	:	3RD FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60612-2345
Country	:	US
Telephone Number	:	773-292-4800
Fax Number	:	773-486-3548

Provider Business Practice Location Address
First Line	:	2003 W FULTON ST
Second Line	:	3RD FLOOR
City	:	CHICAGO
State	:	IL
Zip	:	60612-2345
Country	:	US
Telephone Number	:	773-292-4800
Fax Number	:	773-486-3548

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/20/2005
Last Update Date	:	07/15/2007

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