Provider Demographics
NPI:1316912116
Name:FEDELE, CHARLES ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:ROBERT
Last Name:FEDELE
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 1:1229 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1047
Mailing Address - Country:US
Mailing Address - Phone:570-888-9140
Mailing Address - Fax:
Practice Address - Street 1:1229 PENNSYLVANIA AVENUE
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:PA
Practice Address - Zip Code:18840
Practice Address - Country:US
Practice Address - Phone:570-888-5858
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY119115-1207N00000X
PAMD037378L207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00365155Medicaid
PA0006852070001Medicare ID - Type Unspecified
B34606Medicare UPIN
NY00365155Medicaid
PA059755N8TMedicare ID - Type Unspecified