Provider Demographics
NPI:1730170754
Name:FEDDERSEN, RICHARD M (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:FEDDERSEN
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 1:800 BRADBURY DR SE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87106-4310
Mailing Address - Country:US
Mailing Address - Phone:505-272-1476
Mailing Address - Fax:
Practice Address - Street 1:1100 CENTRAL AVE SE
Practice Address - Street 2:PATHOLOGY ASSOCIATES
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106-4930
Practice Address - Country:US
Practice Address - Phone:505-841-1259
Practice Address - Fax:505-841-1373
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2025-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM87229207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM9597Medicaid
NMS003201047Medicare PIN
A54957Medicare UPIN
NMNM301038Medicare PIN
NM347712205Medicare PIN
NML004601020Medicare PIN
NMNM301037Medicare PIN
NMP002122023Medicare PIN