Provider Demographics
NPI:1992770390
Name:FESENMYER, MARK (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:FESENMYER
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 1:8895 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7037
Mailing Address - Country:US
Mailing Address - Phone:219-738-2081
Mailing Address - Fax:219-736-4658
Practice Address - Street 1:8895 BROADWAY
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7037
Practice Address - Country:US
Practice Address - Phone:219-738-2081
Practice Address - Fax:219-736-4658
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2020-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036105597207RG0100X
IN01072085A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000804383OtherANTHEM
IL036105597Medicaid
IN201131780AMedicaid
ILL88021Medicare ID - Type Unspecified
IN201131780AMedicaid