Basic Information
| Provider Information | |||||||||
| NPI: | 1548349871 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FEDORIW | ||||||||
| FirstName: | WIACHESLAW | ||||||||
| MiddleName: | WILLIAM | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3030 LAKE AVE | ||||||||
| Address2: | #25A | ||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468055428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2604224096 | ||||||||
| FaxNumber: | 2604242551 | ||||||||
| Practice Location | |||||||||
| Address1: | 2710 LAKE AVE | ||||||||
| Address2: | |||||||||
| City: | FORT WAYNE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 468055412 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2603738070 | ||||||||
| FaxNumber: | 2603738071 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2006 | ||||||||
| LastUpdateDate: | 06/09/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 10137509 | IN | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 10013063A | 05 | IN | MEDICAID | 10013063 | 05 | IN | MEDICAID |