Basic Information
| Provider Information | |||||||||
| NPI: | 1346433422 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FEDERMAN | ||||||||
| FirstName: | ALEXIS | ||||||||
| MiddleName: | WAGMAN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WAGMAN | ||||||||
| OtherFirstName: | ALEXIS | ||||||||
| OtherMiddleName: | LEIGH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | D.O. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1385 E 12 MILE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480712618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483996090 | ||||||||
| FaxNumber: | 2483995282 | ||||||||
| Practice Location | |||||||||
| Address1: | 1385 E 12 MILE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MADISON HEIGHTS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483996090 | ||||||||
| FaxNumber: | 2483995282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/22/2007 | ||||||||
| LastUpdateDate: | 06/27/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | OS10098 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 5101016164 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.