Provider Demographics
NPI:1427035583
Name:FETTERMAN, TIMOTHY (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:FETTERMAN
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:PO BOX 638269
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6950
Mailing Address - Country:US
Mailing Address - Phone:440-816-5950
Mailing Address - Fax:
Practice Address - Street 1:18780 BAGLEY RD STE 104
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44130-3304
Practice Address - Country:US
Practice Address - Phone:440-816-5950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2022-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-071569207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000198967OtherANTHEM
OHCG4860OtherRAILROAD MEDICARE GROUP
OH0105480OtherUNITED HEALTH CARE
OH0843940002OtherDMERC
OH2238199Medicaid
OHP00478745OtherRAILROAD CARE
OH0005168421OtherAETNA
OH080176792OtherRAILROAD MEDICARE PIN
OH84779OtherQUAL CHOICE
OH2001470Medicaid
OHP00701420OtherRAILROAD CARE
OH0843940002OtherDMERC
OH7380131Medicare PIN
OHP00478745OtherRAILROAD CARE
OH2001470Medicaid
OHCG4860OtherRAILROAD MEDICARE GROUP