Healthcare Provider Details

I. General information

NPI: 1649499476
Provider Name (Legal Business Name): MARTIN RYAN FETZER D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 08/07/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1801 S HIGHLAND AVE STE 220
LOMBARD IL
60148-4932
US

IV. Provider business mailing address

PO BOX 713260
CHICAGO IL
60677-1260
US

V. Phone/Fax

Practice location:
  • Phone: 630-967-2225
  • Fax: 630-241-6906
Mailing address:
  • Phone: 630-469-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberOS014454
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number5101017042
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036129085
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number036129085
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: