MEDICARE: MR. DARYL ALVAN FEDAK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry	D7742	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	7696119	OTHER		AETNA
2	1407366	OTHER		UNITED CONCORDIA

General Provider Information

NPI Number	:	1033117288
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. DARYL ALVAN FEDAK

Provider Business Mailing Address
First Line	:	5892 MAIN ST
Second Line	:	STE 1
City	:	SPRINGFIELD
State	:	OR
Zip	:	97478-5496
Country	:	US
Telephone Number	:	541-741-7800
Fax Number	:	541-741-7888

Provider Business Practice Location Address
First Line	:	5892 MAIN ST
Second Line	:	STE 1
City	:	SPRINGFIELD
State	:	OR
Zip	:	97478-5496
Country	:	US
Telephone Number	:	541-741-7800
Fax Number	:	541-741-7888

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	07/08/2007

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