Provider Demographics
NPI:1639835010
Name:FEDYSHYN, TODD WILLIAM (SERVICE COORDINATOR)
Entity Type:Individual
Prefix:
First Name:TODD
Middle Name:WILLIAM
Last Name:FEDYSHYN
Suffix:
Gender:M
Credentials:SERVICE COORDINATOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 BREWSTER ST
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2835
Mailing Address - Country:US
Mailing Address - Phone:607-351-9352
Mailing Address - Fax:
Practice Address - Street 1:45 BREWSTER ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2835
Practice Address - Country:US
Practice Address - Phone:607-351-9352
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-10
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03169371Medicaid