Provider Demographics
NPI:1215007505
Name:SUSAN FEDINEC, D.O. LLC
Entity Type:Organization
Organization Name:SUSAN FEDINEC, D.O. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:FEDINEC
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:815-676-2940
Mailing Address - Street 1:24600 W 127TH ST
Mailing Address - Street 2:SUITE 340 BLDG B
Mailing Address - City:PLAINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60585-9507
Mailing Address - Country:US
Mailing Address - Phone:815-676-2940
Mailing Address - Fax:815-676-2942
Practice Address - Street 1:24600 W 127TH ST
Practice Address - Street 2:BLDG B SUITE 340
Practice Address - City:PLAINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60585-9502
Practice Address - Country:US
Practice Address - Phone:815-676-2940
Practice Address - Fax:815-676-2942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2008-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036 078573261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9932303OtherBLUE CROSS BLUE SHIELD ID
IL036 078573OtherIL STATE LICENSE #
IL9932303OtherBLUE CROSS BLUE SHIELD ID