Provider Demographics
NPI:1922090901
Name:FETTER, MARVIN R (MD)
Entity Type:Individual
Prefix:DR
First Name:MARVIN
Middle Name:R
Last Name:FETTER
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 1:1300 ANNE ST NW
Mailing Address - Street 2:
Mailing Address - City:BEMIDJI
Mailing Address - State:MN
Mailing Address - Zip Code:56601-5103
Mailing Address - Country:US
Mailing Address - Phone:218-751-9746
Mailing Address - Fax:218-759-0620
Practice Address - Street 1:1300 ANNE ST NW
Practice Address - Street 2:
Practice Address - City:BEMIDJI
Practice Address - State:MN
Practice Address - Zip Code:56601-5103
Practice Address - Country:US
Practice Address - Phone:218-751-9746
Practice Address - Fax:218-759-0620
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-045536207X00000X
WI39401-020207X00000X
MN54685207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34444000Medicaid
IL03604536Medicaid
C38256Medicare UPIN
IL589010Medicare ID - Type Unspecified
WI34444000Medicaid