Provider Demographics
NPI:1033163563
Name:FEDIRKO, BOHDAN (MD)
Entity Type:Individual
Prefix:
First Name:BOHDAN
Middle Name:
Last Name:FEDIRKO
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:PO BOX 388309
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60638-8309
Mailing Address - Country:US
Mailing Address - Phone:773-585-7505
Mailing Address - Fax:773-585-7507
Practice Address - Street 1:5255 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60632-4915
Practice Address - Country:US
Practice Address - Phone:773-585-7505
Practice Address - Fax:773-585-7507
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2016-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036098499173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098499Medicaid
ILH79765Medicare UPIN
ILK25388Medicare PIN