Provider Demographics
NPI:1427001742
Name:FELLOWS, DAVID EUGENE (PA-C)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:EUGENE
Last Name:FELLOWS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2537 MOMENTUM PL
Mailing Address - Street 2:EMERGENCY DEPARTMENT
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60689-5325
Mailing Address - Country:US
Mailing Address - Phone:913-205-8995
Mailing Address - Fax:
Practice Address - Street 1:5215 HOLY CROSS PKWY
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1469
Practice Address - Country:US
Practice Address - Phone:574-335-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0894363AS0400X
IN10001321363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200572850BMedicaid
IN000000740513OtherANTHEM
KSF70C417Medicare ID - Type Unspecified
KS763000007Medicare PIN
KS200572850BMedicaid
INM400059255Medicare PIN
OKOK401913Medicare PIN