Healthcare Provider Details

I. General information

NPI: 1336124221
Provider Name (Legal Business Name): BRIAN D FEDGCHIN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2005
Last Update Date: 11/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2422 S BROAD ST 1ST FLOOR
PHILA PA
19145-4418
US

IV. Provider business mailing address

2422 S BROAD ST 1ST FLOOR
PHILA PA
19145-4418
US

V. Phone/Fax

Practice location:
  • Phone: 215-389-1748
  • Fax: 215-389-0604
Mailing address:
  • Phone: 215-389-1748
  • Fax: 215-389-0604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number25MA07513800
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberMD072666L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier0018594810005
Identifier TypeMEDICAID
Identifier StatePA
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: