Provider Demographics
NPI:1689084485
Name:FENNELL, JILL
Entity Type:Individual
Prefix:
First Name:JILL
Middle Name:
Last Name:FENNELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 MAIN ST FL 5
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14203-1009
Mailing Address - Country:US
Mailing Address - Phone:716-323-0034
Mailing Address - Fax:716-323-0292
Practice Address - Street 1:818 ELLICOTT ST
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14203-1021
Practice Address - Country:US
Practice Address - Phone:716-323-0034
Practice Address - Fax:716-323-0292
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-01
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2902062080P0204X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY05953255Medicaid