Provider Demographics
NPI:1962664417
Name:FITTERER, MATTHEW MARK (MS, ATC, CSCS)
Entity Type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:MARK
Last Name:FITTERER
Suffix:
Gender:M
Credentials:MS, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1316 BLUEGRASS LN
Mailing Address - Street 2:
Mailing Address - City:CHAMPAIGN
Mailing Address - State:IL
Mailing Address - Zip Code:61822-2094
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2826 IROQUOIS DR
Practice Address - Street 2:
Practice Address - City:THOMPSONS STATION
Practice Address - State:TN
Practice Address - Zip Code:37179-5003
Practice Address - Country:US
Practice Address - Phone:217-766-2343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0020252255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer