Healthcare Provider Details

I. General information

NPI: 1104899186
Provider Name (Legal Business Name): JAY L. FEDERMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2006
Last Update Date: 12/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PRESIDENTIAL BLVD SUITE 100
BALA CYNWYD PA
19004-1108
US

IV. Provider business mailing address

4060 BUTLER PIKE SUITE 200
PLYMOUTH MEETING PA
19462-1560
US

V. Phone/Fax

Practice location:
  • Phone: 800-331-6634
  • Fax: 267-420-1360
Mailing address:
  • Phone: 800-331-6634
  • Fax: 267-420-1360

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD009276E
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMA04747900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: