Provider Demographics
NPI:1134476450
Name:FETTERMAN, ERIC (DPT)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:FETTERMAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 VINEYARD WAY
Practice Address - Street 2:SUITE 100
Practice Address - City:WEST GROVE
Practice Address - State:PA
Practice Address - Zip Code:19390-8849
Practice Address - Country:US
Practice Address - Phone:610-869-5792
Practice Address - Fax:610-869-5795
Is Sole Proprietor?:No
Enumeration Date:2012-08-06
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD24112225100000X
PAPT023486225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA344338VKFMedicare PIN
MD249457ZBL8Medicare PIN
PAP01318897Medicare PIN