Provider Demographics
NPI:1164403697
Name:FANELLY, JOHN MICHAEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:MICHAEL
Last Name:FANELLY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6650 FRANKFORD AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19135-2540
Mailing Address - Country:US
Mailing Address - Phone:215-335-3338
Mailing Address - Fax:
Practice Address - Street 1:6650 FRANKFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19135-2540
Practice Address - Country:US
Practice Address - Phone:215-335-3338
Practice Address - Fax:215-335-9844
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2009-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC002579L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAFA117933Medicare ID - Type Unspecified
PAT29204Medicare UPIN
PAFA117933Medicare PIN
PA0951030001Medicare NSC