MEDICARE: KELLY BOSSENBROEK FEDORIW MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	2008-01856	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1285674606
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY BOSSENBROEK FEDORIW MD

Provider Business Mailing Address
First Line	:	590 MANNING DR
Second Line	:
City	:	CHAPEL HILL
State	:	NC
Zip	:	27599-6119
Country	:	US
Telephone Number	:	919-966-0210
Fax Number	:	919-966-2126

Provider Business Practice Location Address
First Line	:	590 MANNING DR
Second Line	:
City	:	CHAPEL HILL
State	:	NC
Zip	:	27599-6119
Country	:	US
Telephone Number	:	919-966-0210
Fax Number	:	919-966-2126

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	03/31/2021

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