Provider Demographics
NPI:1093812802
Name:FETSKO, STEPHEN F
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:F
Last Name:FETSKO
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 1:1070 OLD NATIONAL PIKE
Mailing Address - Street 2:
Mailing Address - City:FREDERICKTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15333-2114
Mailing Address - Country:US
Mailing Address - Phone:724-632-6801
Mailing Address - Fax:734-632-6312
Practice Address - Street 1:601 W GEORGE ST
Practice Address - Street 2:
Practice Address - City:CARMICHAELS
Practice Address - State:PA
Practice Address - Zip Code:15320-1325
Practice Address - Country:US
Practice Address - Phone:724-966-5081
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1007288440093Medicaid
PA328834A764918Medicaid