Healthcare Provider Details

I. General information

NPI: 1932561792
Provider Name (Legal Business Name): BENJAMIN TATE FEDELES M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/22/2016
Last Update Date: 12/10/2024
Certification Date: 12/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 GOODMAN ST
CINCINNATI OH
45219-2364
US

IV. Provider business mailing address

10500 MONTGOMERY RD
MONTGOMERY OH
45242-4402
US

V. Phone/Fax

Practice location:
  • Phone: 513-475-8282
  • Fax:
Mailing address:
  • Phone: 513-865-2246
  • Fax: 513-865-5552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number35.142433
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number35.142433
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: