Provider Demographics
NPI:1639123581
Name:FENNELL, ROGER G (MD)
Entity Type:Individual
Prefix:DR
First Name:ROGER
Middle Name:G
Last Name:FENNELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:502 W FRONT ST
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-2635
Mailing Address - Country:US
Mailing Address - Phone:610-892-4964
Mailing Address - Fax:
Practice Address - Street 1:207 LEGION ROAD
Practice Address - Street 2:
Practice Address - City:BRAWLEY
Practice Address - State:CA
Practice Address - Zip Code:92227
Practice Address - Country:US
Practice Address - Phone:760-351-3409
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD017897E207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA053951Medicare ID - Type Unspecified
A81676Medicare UPIN