Provider Demographics
NPI:1285674606
Name:FEDORIW, KELLY BOSSENBROEK (MD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:BOSSENBROEK
Last Name:FEDORIW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:
Other - Last Name:BOSSENBROEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:590 MANNING DR
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27599-6119
Mailing Address - Country:US
Mailing Address - Phone:919-966-0210
Mailing Address - Fax:919-966-2126
Practice Address - Street 1:590 MANNING DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-6119
Practice Address - Country:US
Practice Address - Phone:919-966-0210
Practice Address - Fax:919-966-2126
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-01856207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004236346Medicaid
CT004236346Medicaid
CT080001830Medicare ID - Type Unspecified