MEDICARE: MR. FREDERICK T FEDOROWICZ PA-C

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	363A00000X	Physician Assistant	5601001212	MI

General Provider Information

NPI Number	:	1306918990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. FREDERICK T FEDOROWICZ PA-C

Provider Business Mailing Address
First Line	:	21 W NOBLE AVE
Second Line	:
City	:	MONROE
State	:	MI
Zip	:	48162-2740
Country	:	US
Telephone Number	:	734-243-4344
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 E LAFAYETTE BLVD
Second Line	:	J426
City	:	DETROIT
State	:	MI
Zip	:	48226-2927
Country	:	US
Telephone Number	:	313-225-8173
Fax Number	:	313-225-0956

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

Provider Enumeration Date	:	11/15/2006
Last Update Date	:	07/08/2007

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