Healthcare Provider Details

I. General information

NPI: 1225356785
Provider Name (Legal Business Name): VINCENT FEDOROWICH MSED, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: VINCE FEDOROWICH MSED, ATC

II. Dates (important events)

Enumeration Date: 05/08/2010
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 E COLLEGE ST
MARSHALL MO
65340
US

IV. Provider business mailing address

500 E COLLEGE ST
MARSHALL MO
65340-3109
US

V. Phone/Fax

Practice location:
  • Phone: 660-831-4195
  • Fax:
Mailing address:
  • Phone: 660-831-4195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number0126001216
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number2016033787
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: