Provider Demographics
NPI:1023013638
Name:FESSENDEN, MICHAEL L (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:FESSENDEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 W FULTON ST
Mailing Address - Street 2:3RD FLOOR
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-2345
Mailing Address - Country:US
Mailing Address - Phone:773-292-4800
Mailing Address - Fax:773-486-3548
Practice Address - Street 1:2003 W FULTON ST
Practice Address - Street 2:3RD FLOOR
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-2345
Practice Address - Country:US
Practice Address - Phone:773-292-4800
Practice Address - Fax:773-486-3548
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-20
Last Update Date:2007-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2003016360207Q00000X
IL36118835207Q00000X
MDD66365207Q00000X
WI43269-020207Q00000X
ND8219207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G94035Medicare UPIN
P36C508Medicare ID - Type Unspecified