Provider Demographics
NPI:1851585087
Name:FEDORAVICIUS, ANDREW (MD)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:
Last Name:FEDORAVICIUS
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 1:6360 S 3000 E
Mailing Address - Street 2:STE 220
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84121-6924
Mailing Address - Country:US
Mailing Address - Phone:801-944-3199
Mailing Address - Fax:801-944-3180
Practice Address - Street 1:6360 SOUTH 3000 EAST, SUITE 310
Practice Address - Street 2:MOUNTAIN WEST GASTROENTEROLOGY
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84121
Practice Address - Country:US
Practice Address - Phone:801-944-3144
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-30
Last Update Date:2016-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6360128-1205207R00000X, 207RG0100X
UT7471341-1205208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist