Provider Demographics
NPI:1831112408
Name:FELLIN, CHRIS WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:CHRIS
Middle Name:WILLIAM
Last Name:FELLIN
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 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:549 FAIR ST
Practice Address - Street 2:
Practice Address - City:BLOOMSBURG
Practice Address - State:PA
Practice Address - Zip Code:17815-1419
Practice Address - Country:US
Practice Address - Phone:570-387-2251
Practice Address - Fax:570-387-2206
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2021-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039209E208M00000X, 207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA325055OtherHEALTH AMERICA
PA50000875OtherCAPITAL BLUE CROSS
PA11629520002Medicaid
PA414586OtherKEYSTONE
PA232809429OtherTRICARE
PA414586OtherBLUE SHIELD
PA110238261OtherRAILROAD MEDICARE
PA118438711OtherDEPARTMENT OF LABOR
PA214604GOtherGEISINGER
PAE21900Medicare UPIN
PA414586Medicare ID - Type Unspecified