MEDICARE: RANDALL C FEDRO MD

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	207Q00000X	Family Medicine Physician	0101037084	VA

General Provider Information

NPI Number	:	1265443550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RANDALL C FEDRO MD

Provider Business Mailing Address
First Line	:	4211 MONARCH WAY 100
Second Line	:
City	:	NORFOLK
State	:	VA
Zip	:	23508-2540
Country	:	US
Telephone Number	:	757-738-1400
Fax Number	:	757-489-3092

Provider Business Practice Location Address
First Line	:	1232 PERIMETER PKWY
Second Line	:	SUITE 101
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-5924
Country	:	US
Telephone Number	:	757-425-8590
Fax Number	:	757-422-5107

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

Provider Enumeration Date	:	08/11/2006
Last Update Date	:	10/26/2015

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