MEDICARE: ALLEN R. FENDERSON 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	0101027355	VA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
3	P00137845	OTHER	VA	RAILROAD MEDICARE

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
2	462019	OTHER	VA	ANTHEM

General Provider Information

NPI Number	:	1205832979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALLEN R. FENDERSON M.D.

Provider Business Mailing Address
First Line	:	860 OMNI BLVD STE 101
Second Line	:
City	:	NEWPORT NEWS
State	:	VA
Zip	:	23606-4430
Country	:	US
Telephone Number	:	757-232-8769
Fax Number	:	757-232-8875

Provider Business Practice Location Address
First Line	:	351 EDWIN DR
Second Line	:	STE 102
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23462-4559
Country	:	US
Telephone Number	:	757-499-5550
Fax Number	:

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

Provider Enumeration Date	:	06/27/2005
Last Update Date	:	03/30/2021

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