Healthcare Provider Details

I. General information

NPI: 1063690469
Provider Name (Legal Business Name): JAMES STEVEN FENOGLIO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2008
Last Update Date: 07/30/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3319 N ELSTON AVE SUITE 200
CHICAGO IL
60618-5811
US

IV. Provider business mailing address

3319 N ELSTON AVE SUITE 200
CHICAGO IL
60618-5811
US

V. Phone/Fax

Practice location:
  • Phone: 773-751-7200
  • Fax: 773-583-4295
Mailing address:
  • Phone: 773-751-7200
  • Fax: 773-583-4295

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number01028954
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number036103995
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: