Provider Demographics
NPI:1114514270
Name:FELLMAN, PETER G
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:G
Last Name:FELLMAN
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 1:1605 DANIEL DR
Mailing Address - Street 2:
Mailing Address - City:MILLBURY
Mailing Address - State:OH
Mailing Address - Zip Code:43447-9822
Mailing Address - Country:US
Mailing Address - Phone:419-508-5399
Mailing Address - Fax:
Practice Address - Street 1:1605 DANIEL DR
Practice Address - Street 2:
Practice Address - City:MILLBURY
Practice Address - State:OH
Practice Address - Zip Code:43447-9822
Practice Address - Country:US
Practice Address - Phone:419-508-5399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-23
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care