Basic Information
| Provider Information | |||||||||
| NPI: | 1215130034 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FEDEN | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 9484 | ||||||||
| Address2: | |||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029409484 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4018542500 | ||||||||
| FaxNumber: | 4018542519 | ||||||||
| Practice Location | |||||||||
| Address1: | 593 EDDY ST | ||||||||
| Address2: | CLAVERICK 2 | ||||||||
| City: | PROVIDENCE | ||||||||
| State: | RI | ||||||||
| PostalCode: | 029034923 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4015191604 | ||||||||
| FaxNumber: | 4012720538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2007 | ||||||||
| LastUpdateDate: | 08/22/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | MD429607 | PA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | MD12715 | RI | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | 207PS0010X | 12715 | RI | N | Allopathic & Osteopathic Physicians | Emergency Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 007060506 | 01 | RI | RI MEDICARE | OTHER | 939025129 | 01 | RI | UEMF GROUP RI MEDICARE | OTHER | JF72799 | 05 | RI | MEDICAID | P00671207 | 01 | RI | RAILROAD MEDICARE | OTHER | 09-30-2008 | 01 | RI | BCBS | OTHER | 10-30-2008 | 01 | RI | NHPRI | OTHER | 110081793A | 05 | RI | MEDICAID | 12/29/2008 | 01 | MA | TUFTS HEALTH PLAN | OTHER | 04/15/2009 | 01 | RI | UNITED HEALTHCARE | OTHER |