Provider Demographics
NPI:1164836987
Name:FEDIW, MICHAEL AUGUSTINE (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:AUGUSTINE
Last Name:FEDIW
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:PO BOX 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-648-2733
Mailing Address - Fax:214-648-9207
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-5744
Practice Address - Country:US
Practice Address - Phone:214-648-2733
Practice Address - Fax:214-648-9207
Is Sole Proprietor?:No
Enumeration Date:2014-06-19
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS94-08473208100000X
MI4301114958208100000X
TXS2578208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation