Provider Demographics
NPI:1194907998
Name:JOHN M FIDLER
Entity type:Organization
Organization Name:JOHN M FIDLER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:FIDLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:717-334-1810
Mailing Address - Street 1:26 BALTIMORE ST
Mailing Address - Street 2:MARTIN FAMILY SHOES
Mailing Address - City:GETTYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17325
Mailing Address - Country:US
Mailing Address - Phone:717-334-1810
Mailing Address - Fax:717-334-1810
Practice Address - Street 1:26 BALTIMORE ST
Practice Address - Street 2:MARTIN FAMILY SHOES
Practice Address - City:GETTYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17325
Practice Address - Country:US
Practice Address - Phone:717-334-1810
Practice Address - Fax:717-334-1810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2008-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
4132010001Medicare UPIN
1164542437Medicare UPIN
4132010001Medicare NSC