Provider Demographics
NPI:1548250855
Name:FEDORONKO, LORI MARCUM
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:MARCUM
Last Name:FEDORONKO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:IRENE
Other - Last Name:FEDORONKO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1350 KIRTS BLVD
Mailing Address - Street 2:SUITE 155
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4851
Mailing Address - Country:US
Mailing Address - Phone:248-362-0222
Mailing Address - Fax:248-362-1165
Practice Address - Street 1:1350 KIRTS BLVD
Practice Address - Street 2:SUITE 155
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4851
Practice Address - Country:US
Practice Address - Phone:248-362-0222
Practice Address - Fax:248-362-1165
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2024-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064064207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3415994Medicaid
G56093Medicare UPIN
MI3415994Medicaid