MEDICARE: MARK ALLEN FERNANDEZ 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	207R00000X	Internal Medicine Physician	036-089936	IL
2	208000000X	Pediatrics Physician	036089936	IL
3	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	036089936	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1033114939
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK ALLEN FERNANDEZ M.D.

Provider Business Mailing Address
First Line	:	920 WEST ST
Second Line	:	STE 311
City	:	PERU
State	:	IL
Zip	:	61354-2770
Country	:	US
Telephone Number	:	815-223-9214
Fax Number	:	815-223-9322

Provider Business Practice Location Address
First Line	:	920 WEST ST
Second Line	:	STE 311
City	:	PERU
State	:	IL
Zip	:	61354-2770
Country	:	US
Telephone Number	:	815-223-9214
Fax Number	:	815-223-9322

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

Provider Enumeration Date	:	06/16/2005
Last Update Date	:	11/20/2008

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