Provider Demographics
NPI:1174514384
Name:FEDAK, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FEDAK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 419052
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-9052
Mailing Address - Country:US
Mailing Address - Phone:314-851-1000
Mailing Address - Fax:
Practice Address - Street 1:13303 TESSON FERRY RD
Practice Address - Street 2:SUITE 150
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63128-4062
Practice Address - Country:US
Practice Address - Phone:314-842-4744
Practice Address - Fax:314-842-3835
Is Sole Proprietor?:No
Enumeration Date:2005-11-04
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36371207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO100609OtherHEALTHLINK
MO25552OtherBCBS
MO127478OtherGHP
MO0400399OtherUHC
MO000000010015OtherESSENCE
MOA29062OtherMERCY
MO0400399OtherUHC
MO100609OtherHEALTHLINK
MO25552OtherBCBS
MO127478OtherGHP