Provider Demographics
NPI:1841249786
Name:FENNEMA, MARK
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FENNEMA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 BOWER HILL RD
Mailing Address - Street 2:ST CLAIR HOSPITAL - AFFILIATE BILLING - PAMALYN PATNESK
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15243-1873
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 BOWER HILL RD
Practice Address - Street 2:UPMC PASSAVANT HOSPITAL
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15243-1873
Practice Address - Country:US
Practice Address - Phone:412-942-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS007405E207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001237338Medicaid
PAC94580Medicare UPIN