Basic Information
| Provider Information | |||||||||
| NPI: | 1306846407 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FENWICK | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 960 E WALNUT LAWN ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658077506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178753000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 960 E WALNUT LAWN ST | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | SPRINGFIELD | ||||||||
| State: | MO | ||||||||
| PostalCode: | 658077506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178753600 | ||||||||
| FaxNumber: | 4178753612 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/29/2005 | ||||||||
| LastUpdateDate: | 12/27/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | 15294 | SC | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 2005041177 | MO | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 152998 | 05 | SC | MEDICAID | 200282606 | 05 | MO | MEDICAID |