Healthcare Provider Details

I. General information

NPI: 1538361795
Provider Name (Legal Business Name): CHRISTOPHER J FEDOR ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 12/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

MCBRIDE CLINIC, INC. 815 NW 12TH
OKLAHOMA CITY OK
73103
US

IV. Provider business mailing address

9600 BROADWAY EXT
OKLAHOMA CITY OK
73114-7408
US

V. Phone/Fax

Practice location:
  • Phone: 405-230-9575
  • Fax: 405-228-2569
Mailing address:
  • Phone: 405-230-9575
  • Fax: 405-230-9585

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246Z00000X
TaxonomyOther Specialist/Technologist
License Number426
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number426
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: