1215007505 NPI number — SUSAN FEDINEC, D.O. LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215007505 NPI number — SUSAN FEDINEC, D.O. LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SUSAN FEDINEC, D.O. LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1215007505
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
24600 W 127TH ST
Provider Second Line Business Mailing Address:
SUITE 340 BLDG B
Provider Business Mailing Address City Name:
PLAINFIELD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60585-9507
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
815-676-2940
Provider Business Mailing Address Fax Number:
815-676-2942

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
24600 W 127TH ST
Provider Second Line Business Practice Location Address:
BLDG B SUITE 340
Provider Business Practice Location Address City Name:
PLAINFIELD
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60585-9502
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
815-676-2940
Provider Business Practice Location Address Fax Number:
815-676-2942
Provider Enumeration Date:
11/08/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FEDINEC
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
815-676-2940

Provider Taxonomy Codes

  • Taxonomy code: 261Q00000X , with the licence number:  036 078573 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 9932303 . This is a "BLUE CROSS BLUE SHIELD ID" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036 078573 . This is a "IL STATE LICENSE #" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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