Provider Demographics
NPI:1023039674
Name:FEDERER, HOWARD CLARK III (MD)
Entity Type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:CLARK
Last Name:FEDERER
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2740 W FOSTER AVE STE 213
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3532
Mailing Address - Country:US
Mailing Address - Phone:773-293-4001
Mailing Address - Fax:773-293-3203
Practice Address - Street 1:2740 W FOSTER AVE
Practice Address - Street 2:SUITE 213
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-3500
Practice Address - Country:US
Practice Address - Phone:773-293-4001
Practice Address - Fax:773-293-3203
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036072388208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-072388Medicaid
406120103OtherPTAN
ILE76781Medicare UPIN