Provider Demographics
NPI:1629048632
Name:FEDEC, STEPHEN G (DO)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:G
Last Name:FEDEC
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 746652
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-6652
Mailing Address - Country:US
Mailing Address - Phone:904-202-2092
Mailing Address - Fax:904-376-4075
Practice Address - Street 1:400 COLONNADE DR STE 230
Practice Address - Street 2:
Practice Address - City:PONTE VEDRA
Practice Address - State:FL
Practice Address - Zip Code:32081-6237
Practice Address - Country:US
Practice Address - Phone:904-271-7540
Practice Address - Fax:904-376-3204
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2025-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS9424207RC0000X, 207RI0011X
NJ25MB0593880207RC0000X
SC83246207RC0000X
GA30762207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC832460Medicaid
NJ841912OtherAETNA/HMO
NJ7658360OtherCIGNA
NJ4319872OtherAETNA/ PPO
NJ060053149OtherRAILROAD MEDICARE
NJ223621389OtherTAX ID
NJ7545207Medicaid
NJD29442Medicare UPIN
NJ060053149OtherRAILROAD MEDICARE