1902868383 NPI number — CRAIG M FETTERMAN DO

Table of content: CRAIG M FETTERMAN DO (NPI 1902868383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902868383 NPI number — CRAIG M FETTERMAN DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FETTERMAN
Provider First Name:
CRAIG
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1902868383
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/26/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
40 MAIN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HAMBURG
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
14075-4948
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
716-649-0887
Provider Business Mailing Address Fax Number:
716-646-4611

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2950 ELMWOOD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENMORE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
14217-1304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
716-634-8800
Provider Business Practice Location Address Fax Number:
716-634-8987
Provider Enumeration Date:
04/03/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  230757 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208M00000X , with the licence number: 230757-1 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0412489 . This is a "INDEPENDENT HEALTH" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000527760001 . This is a "BC/BS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 0026827302 . This is a "UNIVERA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02533062 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 041006000116 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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