Provider Demographics
NPI:1285779751
Name:CRAIG M. FETTERMAN, D.O.,P.C.
Entity type:Organization
Organization Name:CRAIG M. FETTERMAN, D.O.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:M
Authorized Official - Last Name:FETTERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:716-634-8800
Mailing Address - Street 1:200 INTERNATIONAL DR
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8217
Mailing Address - Country:US
Mailing Address - Phone:716-634-8800
Mailing Address - Fax:716-634-8987
Practice Address - Street 1:2950 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:NY
Practice Address - Zip Code:14217-1304
Practice Address - Country:US
Practice Address - Phone:716-634-8800
Practice Address - Fax:716-634-8987
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230757-1208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02533062Medicaid
NY00026827302OtherUNIVERA
NY0412489OtherINDEPENDENT HEALTH
NY061106000022OtherFIDELIS
NYI10628Medicare UPIN
NY0412489OtherINDEPENDENT HEALTH