MEDICARE: DR. RISHA RAVEN FENNELL MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	036100518	IL
2	207QA0401X	Addiction Medicine (Family Medicine) Physician	036100518	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1487622379
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RISHA RAVEN FENNELL MD

Provider Business Mailing Address
First Line	:	900 BEECH ST
Second Line	:
City	:	NORMAL
State	:	IL
Zip	:	61761-1803
Country	:	US
Telephone Number	:	779-429-2227
Fax Number	:

Provider Business Practice Location Address
First Line	:	2501 CHATHAM RD STE 4713
Second Line	:
City	:	SPRINGFIELD
State	:	IL
Zip	:	62704-4188
Country	:	US
Telephone Number	:	779-429-2227
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/08/2006
Last Update Date	:	06/07/2024

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