Healthcare Provider Details

I. General information

NPI: 1477188571
Provider Name (Legal Business Name): RONALD FIEDLER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2020
Last Update Date: 03/09/2020
Certification Date: 03/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23770 HOSPITAL ST
CASSOPOLIS MI
49031-9644
US

IV. Provider business mailing address

1448 OLD SAUK TRL
NILES MI
49120-3152
US

V. Phone/Fax

Practice location:
  • Phone: 269-445-3801
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number5502002619
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: