Provider Demographics
NPI:1255316386
Name:FELLECHNER, BRIAN L (DO)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:L
Last Name:FELLECHNER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 ST LUKES BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:EASTON
Mailing Address - State:PA
Mailing Address - Zip Code:18045-5670
Mailing Address - Country:US
Mailing Address - Phone:484-503-0050
Mailing Address - Fax:484-503-0003
Practice Address - Street 1:1700 ST LUKES BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:EASTON
Practice Address - State:PA
Practice Address - Zip Code:18045-5670
Practice Address - Country:US
Practice Address - Phone:484-503-0050
Practice Address - Fax:484-503-0003
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS006405L208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA00120814900005Medicaid
PA0012081490005Medicaid
143301Medicare PIN
E65832Medicare UPIN