Provider Demographics
NPI:1336149939
Name:FEDOR, RALPH E (MD)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:E
Last Name:FEDOR
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:PO BOX 7366
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56302-7366
Mailing Address - Country:US
Mailing Address - Phone:320-255-5619
Mailing Address - Fax:320-656-7068
Practice Address - Street 1:1406 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1900
Practice Address - Country:US
Practice Address - Phone:320-255-5619
Practice Address - Fax:320-656-7068
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN197002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN54888FEOtherBLUE CROSS BLUE SHIELD
MNHP25433OtherHEALTH PARTNERS
MN26646OtherARAZ/ AMERICA'S PPO
MN16-29698OtherMEDICA
MN965251008758OtherPREFERRED ONE
MN16-29698OtherMEDICA