Healthcare Provider Details

I. General information

NPI: 1285779751
Provider Name (Legal Business Name): CRAIG M. FETTERMAN, D.O.,P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2950 ELMWOOD AVE
KENMORE NY
14217-1304
US

IV. Provider business mailing address

200 INTERNATIONAL DR
WILLIAMSVILLE NY
14221-8217
US

V. Phone/Fax

Practice location:
  • Phone: 716-634-8800
  • Fax: 716-634-8987
Mailing address:
  • Phone: 716-634-8800
  • Fax: 716-634-8987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number230757-1
License Number StateNY

VIII. Authorized Official

Name: DR. CRAIG M FETTERMAN
Title or Position: PRESIDENT
Credential: D.O.
Phone: 716-634-8800