Provider Demographics
NPI:1851779052
Name:FENLON, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:FENLON
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 1:225 EAST CHICAGO AVENUE
Mailing Address - Street 2:BOX#57
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:225 EAST CHICAGO AVENUE
Practice Address - Street 2:BOX#57
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-227-4646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-08
Last Update Date:2023-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361665472086S0120X
CA135974208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery