Individual
MICHAEL LYNN FETTEROLF
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1405 MILL ST, NEW LONDON, WI 54961-2155
(920) 531-2400
Mailing address
PO BOX 8003, APPLETON, WI 54912-8003
(920) 996-3200
(920) 738-5787
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
55231-20
WI
207Q00000X
Family Medicine Physician
MD031976E
PA
207VX0000X
Obstetrics Physician
MD031976E
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
0010419750001
—
PA
01
—
160011217
RAILROAD MEDICARE
PA
01
—
450030702
MEDICARE PTAN
WI
Enumeration date
01/30/2006
Last updated
12/11/2020
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