Provider Demographics
NPI:1093812430
Name:FEDERMAN, CAROLYN (MD)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:
Last Name:FEDERMAN
Suffix:
Gender:F
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 387
Mailing Address - Street 2:
Mailing Address - City:ADDISON
Mailing Address - State:IL
Mailing Address - Zip Code:60101-0387
Mailing Address - Country:US
Mailing Address - Phone:847-686-0037
Mailing Address - Fax:
Practice Address - Street 1:4180 ROUTE 83
Practice Address - Street 2:SUITE 10
Practice Address - City:LONG GROVE
Practice Address - State:IL
Practice Address - Zip Code:60047
Practice Address - Country:US
Practice Address - Phone:847-686-0037
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4932106OtherBCBS PROVIDER NUMBER