Provider Demographics
NPI:1407809296
Name:FEDALEI, ALBERT GEORGE (MD)
Entity type:Individual
Prefix:
First Name:ALBERT
Middle Name:GEORGE
Last Name:FEDALEI
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 1:1 INDEPENDENCE PT
Mailing Address - Street 2:SUITE 212
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29615-4545
Mailing Address - Country:US
Mailing Address - Phone:864-797-6044
Mailing Address - Fax:
Practice Address - Street 1:11 DOCTORS PARK DRIVE
Practice Address - Street 2:SUITE 240
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29307-1008
Practice Address - Country:US
Practice Address - Phone:864-573-3593
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC19601207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC576007863161OtherBCBS OF SC
SCP00685025OtherRR MEDICARE
SC196013Medicaid
SCG529063640Medicare PIN
SCP00685025OtherRR MEDICARE
SC196013Medicaid