Provider Demographics
NPI:1316194285
Name:FENNER PLASTIC SURGERY, LTD.
Entity Type:Organization
Organization Name:FENNER PLASTIC SURGERY, LTD.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEOFFREY
Authorized Official - Middle Name:CRAIG
Authorized Official - Last Name:FENNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-716-2400
Mailing Address - Street 1:512 GREEN BAY RD
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:IL
Mailing Address - Zip Code:60043-1073
Mailing Address - Country:US
Mailing Address - Phone:847-716-2400
Mailing Address - Fax:847-716-2401
Practice Address - Street 1:512 GREEN BAY RD
Practice Address - Street 2:
Practice Address - City:KENILWORTH
Practice Address - State:IL
Practice Address - Zip Code:60043-1073
Practice Address - Country:US
Practice Address - Phone:847-716-2400
Practice Address - Fax:847-716-2401
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-22
Last Update Date:2020-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081864208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL1037Medicare PIN