Provider Demographics
NPI:1952844284
Name:FEDORE, RYAN (DPT)
Entity Type:Individual
Prefix:DR
First Name:RYAN
Middle Name:
Last Name:FEDORE
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 S HEALTH PKWY
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-8350
Mailing Address - Country:US
Mailing Address - Phone:269-273-9682
Mailing Address - Fax:269-273-9626
Practice Address - Street 1:501 S HEALTH PKWY
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-8350
Practice Address - Country:US
Practice Address - Phone:269-273-9682
Practice Address - Fax:269-273-9626
Is Sole Proprietor?:No
Enumeration Date:2016-11-18
Last Update Date:2016-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501014610225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist