Healthcare Provider Details

I. General information

NPI: 1770575862
Provider Name (Legal Business Name): ILENE FENNOY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2005
Last Update Date: 09/22/2026
Certification Date: 09/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3959 BROADWAY CHN 106
NEW YORK NY
10032
US

IV. Provider business mailing address

630 W 168TH ST PH5E 522
NEW YORK NY
10032
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-6559
  • Fax: 212-305-4778
Mailing address:
  • Phone: 212-305-6559
  • Fax: 212-305-4778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number122361
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number122361
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: