Provider Demographics
NPI:1326100108
Name:FENSTERBUSCH, MARY ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:ANN
Last Name:FENSTERBUSCH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:DR
Other - First Name:MARY
Other - Middle Name:ANN
Other - Last Name:HANFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:202 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:GENESEO
Mailing Address - State:IL
Mailing Address - Zip Code:61254-1322
Mailing Address - Country:US
Mailing Address - Phone:309-944-3208
Mailing Address - Fax:
Practice Address - Street 1:202 W 2ND ST
Practice Address - Street 2:
Practice Address - City:GENESEO
Practice Address - State:IL
Practice Address - Zip Code:61254-1322
Practice Address - Country:US
Practice Address - Phone:309-944-3208
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03708465OtherBCBSIL
IL729680Medicare ID - Type Unspecified
ILT38254Medicare UPIN