Provider Demographics
NPI:1952441156
Name:FEDISON, JAMES W (PT)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:W
Last Name:FEDISON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1970 ROANOKE BLVD
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-6404
Mailing Address - Country:US
Mailing Address - Phone:540-982-2463
Mailing Address - Fax:540-983-1038
Practice Address - Street 1:1970 ROANOKE BLVD
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-6404
Practice Address - Country:US
Practice Address - Phone:540-982-2463
Practice Address - Fax:540-983-1038
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2305202002225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA193442OtherANTHEM PT LOC 5
VA193434OtherANTHEM PT LOC 2
VA193437OtherANTHEM PT LOC 3
VA249624OtherANTHEM PT LOC 6
VA193431OtherANTHEM PT LOC 1
VA193434OtherANTHEM PT LOC 2