Healthcare Provider Details

I. General information

NPI: 1912905795
Provider Name (Legal Business Name): CRAIG SHERMAN FEASTER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2005
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 ROLLING RIDGE DR SUITE 100
STATE COLLEGE PA
16801-7641
US

IV. Provider business mailing address

320 ROLLING RIDGE DR SUITE 100
STATE COLLEGE PA
16801-7641
US

V. Phone/Fax

Practice location:
  • Phone: 814-867-0670
  • Fax: 814-867-7616
Mailing address:
  • Phone: 814-867-0670
  • Fax: 814-867-7616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberMD 072243 L
License Number StatePA

VII. Legacy identifiers

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

# 1
Identifier18467600002
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: