Provider Demographics
NPI:1578744918
Name:20TH STREET CLINIC PC
Entity Type:Organization
Organization Name:20TH STREET CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:
Authorized Official - Last Name:FEDELE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:269-969-6010
Mailing Address - Street 1:105 N 20TH ST
Mailing Address - Street 2:
Mailing Address - City:BATTLE CREEK
Mailing Address - State:MI
Mailing Address - Zip Code:49015-1746
Mailing Address - Country:US
Mailing Address - Phone:269-969-6010
Mailing Address - Fax:269-964-8422
Practice Address - Street 1:105 N 20TH ST
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49015-1746
Practice Address - Country:US
Practice Address - Phone:269-969-6010
Practice Address - Fax:269-964-8422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2013-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101004673207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI080A310650OtherBCBS
MI111023860Medicaid
MI464295OtherADVANTRA FREEDOM
CJ8333OtherRR MCR
010057408OtherRR MCR P-TAN
5130499OtherMEDICARE ADVANTAGE
CJ8333OtherRR MCR
MIE26731Medicare UPIN