Provider Demographics
NPI:1073558284
Name:POLISH AMERICAN MEDICAL CENTER LTD
Entity Type:Organization
Organization Name:POLISH AMERICAN MEDICAL CENTER LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BOHDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FEDIRKO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:630-754-0375
Mailing Address - Street 1:1011 STATE ST
Mailing Address - Street 2:
Mailing Address - City:LEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60439-4768
Mailing Address - Country:US
Mailing Address - Phone:630-754-0375
Mailing Address - Fax:
Practice Address - Street 1:1011 STATE ST
Practice Address - Street 2:
Practice Address - City:LEMONT
Practice Address - State:IL
Practice Address - Zip Code:60439-4768
Practice Address - Country:US
Practice Address - Phone:630-754-0375
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36098499173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILH79765Medicare UPIN
IL213208Medicare ID - Type Unspecified