Provider Demographics
NPI:1215130034
Name:FEDEN, JEFFREY (MD)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:FEDEN
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 9484
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02940-9484
Mailing Address - Country:US
Mailing Address - Phone:401-854-2500
Mailing Address - Fax:401-854-2519
Practice Address - Street 1:593 EDDY ST
Practice Address - Street 2:CLAVERICK 2
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02903-4923
Practice Address - Country:US
Practice Address - Phone:401-519-1604
Practice Address - Fax:401-272-0538
Is Sole Proprietor?:No
Enumeration Date:2007-06-08
Last Update Date:2013-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD429607207P00000X
RIMD12715207P00000X
RI12715207PS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PS0010XAllopathic & Osteopathic PhysiciansEmergency MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007060506OtherRI MEDICARE
RI939025129OtherUEMF GROUP RI MEDICARE
RIJF72799Medicaid
RIP00671207OtherRAILROAD MEDICARE
RI09-30-2008OtherBCBS
RI10-30-2008OtherNHPRI
RI110081793AMedicaid
MA12/29/2008OtherTUFTS HEALTH PLAN
RI04/15/2009OtherUNITED HEALTHCARE