Provider Demographics
NPI:1487622379
Name:FENNELL, RISHA RAVEN (MD)
Entity type:Individual
Prefix:DR
First Name:RISHA
Middle Name:RAVEN
Last Name:FENNELL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RISHA
Other - Middle Name:O'CONNOR
Other - Last Name:RAVEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:900 BEECH ST
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-1803
Mailing Address - Country:US
Mailing Address - Phone:779-429-2227
Mailing Address - Fax:
Practice Address - Street 1:2501 CHATHAM RD STE 4713
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4188
Practice Address - Country:US
Practice Address - Phone:779-429-2227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036100518207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036100518Medicaid
IL036100518Medicaid
ILL77274Medicare PIN