Provider Demographics
NPI:1649342817
Name:FEDERSPIEL, RICHARD ALAN (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:ALAN
Last Name:FEDERSPIEL
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 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:915 SAGAMORE PKWY W
Practice Address - Street 2:
Practice Address - City:WEST LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47906-1443
Practice Address - Country:US
Practice Address - Phone:765-463-2424
Practice Address - Fax:765-463-2249
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-14
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026230174400000X
IN01026230A207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN070015351OtherMEDICARE RAILROAD
IN000000085566OtherBLUE CROSS BLUE SHIELD
IN000000085566OtherBLUE CROSS BLUE SHIELD
IN070015351OtherMEDICARE RAILROAD