Provider Demographics
NPI:1619077138
Name:MARIAN A. FEDAK M.D. MEDICAL CORPORATION
Entity Type:Organization
Organization Name:MARIAN A. FEDAK M.D. MEDICAL CORPORATION
Other - Org Name:VMV MEDICAL ASSOCIATES, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MARIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:FEDAK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:323-264-4114
Mailing Address - Street 1:PO BOX 6865
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90734-6865
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 E CESAR E CHAVEZ AVE
Practice Address - Street 2:SUITE 3300
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-2424
Practice Address - Country:US
Practice Address - Phone:323-264-4114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-24
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG186240174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G186240Medicaid
CAGR0077680Medicaid
CA00G186240Medicaid