Basic Information
| Provider Information | |||||||||
| NPI: | 1275634495 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FEDORE | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 791 | ||||||||
| Address2: | |||||||||
| City: | CARNEGIE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151060791 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4126554362 | ||||||||
| FaxNumber: | 4125047702 | ||||||||
| Practice Location | |||||||||
| Address1: | 2490 MOSSIDE BLVD | ||||||||
| Address2: | |||||||||
| City: | MONROEVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 151464236 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4126098130 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 11/01/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | DC009385 | PA | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | 1736661 | 01 | PA | HIGHMARK | OTHER |