Provider Demographics
NPI:1679684476
Name:FELLIN, FREDERICK M (MD)
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:M
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 1:925 CHESTNUT STREET
Mailing Address - Street 2:SUITE 320A
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5109
Mailing Address - Country:US
Mailing Address - Phone:215-955-8874
Mailing Address - Fax:
Practice Address - Street 1:925 CHESTNUT STREET
Practice Address - Street 2:SUITE 320A
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107-5109
Practice Address - Country:US
Practice Address - Phone:215-955-8874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD025210E207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA007005116Medicaid
PA110046099OtherPALMETTO GBA RAILROAD MEDICARE
PA52134OtherAETNA
NJ0311955Medicaid
PA007005116Medicaid
PA430461Medicare PIN