Provider Demographics
NPI:1376648444
Name:FELLERMAN, HERBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:HERBERT
Middle Name:
Last Name:FELLERMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:644 GIBSON AVE
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:PA
Mailing Address - Zip Code:18704-5320
Mailing Address - Country:US
Mailing Address - Phone:570-283-4806
Mailing Address - Fax:570-283-3044
Practice Address - Street 1:183 MARKET ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:PA
Practice Address - Zip Code:18704-5444
Practice Address - Country:US
Practice Address - Phone:570-714-9322
Practice Address - Fax:570-714-8750
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMDO10836E207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006517730005Medicaid
PA0006517730005Medicaid
PAB33182Medicare UPIN