Provider Demographics
NPI:1205962495
Name:FANELLI, JOSEPH G (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:G
Last Name:FANELLI
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 1:493 S PARKSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:IL
Mailing Address - Zip Code:60126-3935
Mailing Address - Country:US
Mailing Address - Phone:630-728-6247
Mailing Address - Fax:630-216-7025
Practice Address - Street 1:419 RIDGE RD STE E
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1535
Practice Address - Country:US
Practice Address - Phone:630-728-6247
Practice Address - Fax:630-216-7025
Is Sole Proprietor?:No
Enumeration Date:2007-02-24
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360760002084P0800X
IN01071173A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILL17336Medicare PIN
ILC44450Medicare UPIN