Provider Demographics
NPI:1528019437
Name:FENTON, CRAIG A (MD)
Entity Type:Individual
Prefix:DR
First Name:CRAIG
Middle Name:A
Last Name:FENTON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:411 HAMILTON BLVD
Mailing Address - Street 2:SUITE 1824
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61602-1144
Mailing Address - Country:US
Mailing Address - Phone:309-494-9320
Mailing Address - Fax:309-494-9321
Practice Address - Street 1:5200 RELIABLE PARKWAY
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60686-0001
Practice Address - Country:US
Practice Address - Phone:309-671-8748
Practice Address - Fax:309-671-8740
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC40336Medicare UPIN
ILL81353Medicare PIN