Basic Information
| Provider Information | |||||||||
| NPI: | 1285779751 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CRAIG M. FETTERMAN, D.O.,P.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 INTERNATIONAL DR | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142218217 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166348800 | ||||||||
| FaxNumber: | 7166348987 | ||||||||
| Practice Location | |||||||||
| Address1: | 2950 ELMWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | KENMORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142171304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166348800 | ||||||||
| FaxNumber: | 7166348987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 09/19/2007 | ||||||||
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| AuthorizedOfficialLastName: | FETTERMAN | ||||||||
| AuthorizedOfficialFirstName: | CRAIG | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7166348800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | D.O. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 230757-1 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 02533062 | 05 | NY | MEDICAID | 00026827302 | 01 | NY | UNIVERA | OTHER | 0412489 | 01 | NY | INDEPENDENT HEALTH | OTHER | 061106000022 | 01 | NY | FIDELIS | OTHER |