Basic Information
| Provider Information | |||||||||
| NPI: | 1902868383 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FETTERMAN | ||||||||
| FirstName: | CRAIG | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 40 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | HAMBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 140754948 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166490887 | ||||||||
| FaxNumber: | 7166464611 | ||||||||
| Practice Location | |||||||||
| Address1: | 2950 ELMWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | KENMORE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 142171304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7166348800 | ||||||||
| FaxNumber: | 7166348987 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2006 | ||||||||
| LastUpdateDate: | 08/26/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 230757 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 230757-1 | NY | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 0412489 | 01 | NY | INDEPENDENT HEALTH | OTHER | 000527760001 | 01 | NY | BC/BS | OTHER | 0026827302 | 01 | NY | UNIVERA | OTHER | 02533062 | 05 | NY | MEDICAID | 041006000116 | 01 | NY | FIDELIS | OTHER |