Healthcare Provider Details

I. General information

NPI: 1760551105
Provider Name (Legal Business Name): RUDOLPH SILAS FELLIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

54 N LOCUST ST
HAZLETON PA
18201-5770
US

IV. Provider business mailing address

54 N LOCUST ST
HAZLETON PA
18201-5770
US

V. Phone/Fax

Practice location:
  • Phone: 570-454-8711
  • Fax:
Mailing address:
  • Phone: 570-454-8711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD024942E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: