Provider Demographics
NPI:1629048632
Name:FEDEC, STEPHEN G (DO)
Entity Type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:G
Last Name:FEDEC
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:955 RIBAUT RD
Mailing Address - Street 2:
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5454
Mailing Address - Country:US
Mailing Address - Phone:843-522-7843
Mailing Address - Fax:843-522-5945
Practice Address - Street 1:300 MIDTOWN DR
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29906-5200
Practice Address - Country:US
Practice Address - Phone:843-770-4550
Practice Address - Fax:844-295-9872
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2021-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB0593880207RC0000X
SC83246207RC0000X
GA30762207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC832460Medicaid
NJ841912OtherAETNA/HMO
NJ7658360OtherCIGNA
NJ4319872OtherAETNA/ PPO
NJ060053149OtherRAILROAD MEDICARE
NJ223621389OtherTAX ID
NJ7545207Medicaid
NJD29442Medicare UPIN
NJ060053149OtherRAILROAD MEDICARE