Provider Demographics
NPI:1376865964
Name:ANTHONY FENISON, MD, INC
Entity Type:Organization
Organization Name:ANTHONY FENISON, MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:FENISON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:909-888-2210
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR STE 100
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1728
Mailing Address - Country:US
Mailing Address - Phone:310-474-9809
Mailing Address - Fax:888-652-3017
Practice Address - Street 1:155 W HOSPITALITY LN STE 105
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92408-3317
Practice Address - Country:US
Practice Address - Phone:909-888-2210
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ANTHONY FENISON, MD, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-02-23
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG73330207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG19547Medicare UPIN