Provider Demographics
NPI:1033171699
Name:FEDELE, STEPHEN (DO)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:FEDELE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 N 20TH ST
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015
Mailing Address - Country:US
Mailing Address - Phone:269-969-6010
Mailing Address - Fax:269-964-8422
Practice Address - Street 1:105 N 20TH ST
Practice Address - Street 2:20TH ST CLINIC PC
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015
Practice Address - Country:US
Practice Address - Phone:269-969-6010
Practice Address - Fax:269-964-8422
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101004673207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICJ8333OtherRR MCR
MI5130499OtherMCR ADVANTAGE
MICJ8333OtherRR MCR
E26731Medicare UPIN
MION4483Medicare PIN