Provider Demographics
NPI:1316308513
Name:FEHR, COREY
Entity type:Individual
Prefix:
First Name:COREY
Middle Name:
Last Name:FEHR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 MOYERS STATION RD
Mailing Address - Street 2:
Mailing Address - City:PINE GROVE
Mailing Address - State:PA
Mailing Address - Zip Code:17963-9041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1125 MOYERS STATION RD
Practice Address - Street 2:
Practice Address - City:PINE GROVE
Practice Address - State:PA
Practice Address - Zip Code:17963-9041
Practice Address - Country:US
Practice Address - Phone:570-640-9350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-15
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT291062171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAAJQAN6164486OtherBLUE CROSS BLUE SHIELD