Provider Demographics
NPI:1265633416
Name:LORI FEDORONKO M D P C
Entity Type:Organization
Organization Name:LORI FEDORONKO M D P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:FEDORONKO
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:248-362-0222
Mailing Address - Street 1:1350 KIRTS BLVD
Mailing Address - Street 2:SUITE 155
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4851
Mailing Address - Country:US
Mailing Address - Phone:248-362-0222
Mailing Address - Fax:
Practice Address - Street 1:1350 KIRTS BLVD
Practice Address - Street 2:SUITE 155
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4851
Practice Address - Country:US
Practice Address - Phone:248-362-0222
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILF064064207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3415994Medicaid
MIG56093Medicare PIN