Provider Demographics
NPI:1720014293
Name:FEGELMAN, ELLIOTT JAY (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIOTT
Middle Name:JAY
Last Name:FEGELMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4760 E GALBRAITH RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45236-6703
Mailing Address - Country:US
Mailing Address - Phone:513-791-0707
Mailing Address - Fax:513-936-3536
Practice Address - Street 1:4760 E GALBRAITH RD
Practice Address - Street 2:SUITE 108
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-6703
Practice Address - Country:US
Practice Address - Phone:513-791-0707
Practice Address - Fax:513-936-3536
Is Sole Proprietor?:No
Enumeration Date:2006-06-24
Last Update Date:2011-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH61379208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0759763Medicare PIN
OHF77859Medicare UPIN