Healthcare Provider Details

I. General information

NPI: 1487622379
Provider Name (Legal Business Name): RISHA RAVEN FENNELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RISHA O'CONNOR RAVEN MD

II. Dates (important events)

Enumeration Date: 03/08/2006
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CHATHAM RD STE 4713
SPRINGFIELD IL
62704-4188
US

IV. Provider business mailing address

900 BEECH ST
NORMAL IL
61761-1803
US

V. Phone/Fax

Practice location:
  • Phone: 779-429-2227
  • Fax:
Mailing address:
  • Phone: 779-429-2227
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036100518
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number036100518
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: