Provider Demographics
NPI:1275517294
Name:FEDERMAN, ADAM SAMUEL (MD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:SAMUEL
Last Name:FEDERMAN
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 1:3 ENTERPRISE DR
Mailing Address - Street 2:STE 220
Mailing Address - City:SHELTON
Mailing Address - State:CT
Mailing Address - Zip Code:06484-4694
Mailing Address - Country:US
Mailing Address - Phone:203-696-3670
Mailing Address - Fax:
Practice Address - Street 1:56 QUARRY ROAD
Practice Address - Street 2:56 QUARRY ROAD
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-1351
Practice Address - Country:US
Practice Address - Phone:203-696-3672
Practice Address - Fax:203-696-6130
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2017-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0467462085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02950461Medicaid
NJ7953500Medicaid
CT500000187Medicaid
NJ7953500Medicaid
NY8461200611Medicare PIN
G94655Medicare UPIN
NJ027671Medicare ID - Type Unspecified
NY02950461Medicaid