Healthcare Provider Details

I. General information

NPI: 1497705891
Provider Name (Legal Business Name): ELTON G. FENNELL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 09/11/2025
Certification Date: 09/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 W COLUMBIA ST STE 110
EVANSVILLE IN
47710-1656
US

IV. Provider business mailing address

PO BOX 3407
EVANSVILLE IN
47733-3407
US

V. Phone/Fax

Practice location:
  • Phone: 812-450-3363
  • Fax: 812-450-3071
Mailing address:
  • Phone: 812-450-3363
  • Fax: 812-450-3071

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01074892A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number45090
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01074892A
License Number StateIN
# 4
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number235209
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: