Provider Demographics
NPI:1780885590
Name:FELLWOCK, MARK M (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:M
Last Name:FELLWOCK
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:5218 E 70TH ST
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46220-3838
Mailing Address - Country:US
Mailing Address - Phone:317-465-9046
Mailing Address - Fax:
Practice Address - Street 1:5604 W 74TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46278-1752
Practice Address - Country:US
Practice Address - Phone:317-290-1551
Practice Address - Fax:317-290-2052
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2009-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05004294A2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic