Basic Information
| Provider Information | |||||||||
| NPI: | 1639210008 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ALEXANDR MICHAEL FEDERER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 323 S MCQUEEN ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295014722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436730727 | ||||||||
| FaxNumber: | 8436671549 | ||||||||
| Practice Location | |||||||||
| Address1: | 323 S MCQUEEN ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295014722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436730727 | ||||||||
| FaxNumber: | 8436671549 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/09/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | FEDERER | ||||||||
| AuthorizedOfficialFirstName: | ALEXANDR | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | LICENSED CLINICAL PSYCHOLOGIST | ||||||||
| AuthorizedOfficialTelephone: | 8436730727 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | PH.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 569 | SC | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
ID Information
| ID | Type | State | Issuer | Description | PS0173 | 05 | SC | MEDICAID |