Provider Demographics
NPI:1306949557
Name:FEDELE, GREGORY MALCOLM (MD FACS)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:MALCOLM
Last Name:FEDELE
Suffix:
Gender:M
Credentials:MD FACS
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 1086
Mailing Address - Street 2:
Mailing Address - City:WILLOUGHBY
Mailing Address - State:OH
Mailing Address - Zip Code:44096-1086
Mailing Address - Country:US
Mailing Address - Phone:216-645-7242
Mailing Address - Fax:440-975-8278
Practice Address - Street 1:25201 CHAGRIN BLVD
Practice Address - Street 2:SUITE 180
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5600
Practice Address - Country:US
Practice Address - Phone:216-464-1616
Practice Address - Fax:216-464-1618
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2015-07-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
OH35.070501208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2500289Medicaid
OHFE4043414Medicare PIN
OH2500289Medicaid