Provider Demographics
NPI:1366477549
Name:FENWICK, JERRY (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:FENWICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JERRY
Other - Middle Name:LYNN
Other - Last Name:FENWICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:771 N SUMMERCREEK CT
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65802-7249
Mailing Address - Country:US
Mailing Address - Phone:417-714-4548
Mailing Address - Fax:
Practice Address - Street 1:771 N SUMMERCREEK CT
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-7249
Practice Address - Country:US
Practice Address - Phone:417-771-4548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18407207P00000X
MO110179207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208524116Medicaid
MO1366477549Medicaid
SCG38753Medicaid