Healthcare Provider Details

I. General information

NPI: 1992770390
Provider Name (Legal Business Name): MARK FESENMYER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2006
Last Update Date: 05/05/2020
Certification Date: 05/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8895 BROADWAY
MERRILLVILLE IN
46410-7037
US

IV. Provider business mailing address

8895 BROADWAY
MERRILLVILLE IN
46410-7037
US

V. Phone/Fax

Practice location:
  • Phone: 219-738-2081
  • Fax: 219-736-4658
Mailing address:
  • Phone: 219-738-2081
  • Fax: 219-736-4658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number036105597
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01072085A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: