Provider Demographics
NPI:1316375132
Name:FEDEWA, BENJAMIN (DPT)
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:
Last Name:FEDEWA
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 DEWEY AVE NW
Mailing Address - Street 2:STE 300
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-5283
Mailing Address - Country:US
Mailing Address - Phone:616-356-5000
Mailing Address - Fax:616-356-5001
Practice Address - Street 1:4341 PIEDMONT AVE STE 201
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-4792
Practice Address - Country:US
Practice Address - Phone:510-547-1630
Practice Address - Fax:510-923-1844
Is Sole Proprietor?:No
Enumeration Date:2013-10-15
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT60415927225100000X
CAPT295677225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0318505OtherL&I
WA0318649OtherL&I
WA0318507OtherL&I
WA031853OtherL&I
WA0318505OtherL&I
WAG8924494Medicare PIN
WAGG8924493Medicare PIN
WAG8924492Medicare PIN
WA0318507OtherL&I