Provider Demographics
NPI:1619263647
Name:FEWELL, GINGER (MD)
Entity Type:Individual
Prefix:
First Name:GINGER
Middle Name:
Last Name:FEWELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:705 S GRAND ST
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62263-1534
Mailing Address - Country:US
Mailing Address - Phone:618-327-2225
Mailing Address - Fax:
Practice Address - Street 1:705 S GRAND ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:IL
Practice Address - Zip Code:62263-1534
Practice Address - Country:US
Practice Address - Phone:618-327-2225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.134709207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine