Provider Demographics
NPI:1316922685
Name:FEDERMAN, ROBERT JAY (MD)
Entity type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:JAY
Last Name:FEDERMAN
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 1:39450 W 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-3600
Mailing Address - Country:US
Mailing Address - Phone:248-344-0710
Mailing Address - Fax:248-344-0720
Practice Address - Street 1:39450 W 12 MILE RD
Practice Address - Street 2:
Practice Address - City:NOVI
Practice Address - State:MI
Practice Address - Zip Code:48377-3600
Practice Address - Country:US
Practice Address - Phone:248-344-0710
Practice Address - Fax:248-344-0720
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0097352207R00000X
MI4301074380207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2779625-00Medicaid
MI0N65510-004Medicaid
MI0N65510-004Medicaid