Provider Demographics
NPI:1235261264
Name:FEDERBUSCH, JOHN PAUL (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PAUL
Last Name:FEDERBUSCH
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 1:832 W OAKDALE AVE APT 3F
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-5111
Mailing Address - Country:US
Mailing Address - Phone:630-776-4923
Mailing Address - Fax:630-629-3901
Practice Address - Street 1:2333 W IRVING PARK RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618
Practice Address - Country:US
Practice Address - Phone:773-506-7340
Practice Address - Fax:773-506-7341
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036056863202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036056863Medicaid
IL787360OtherMEDICARE GROUP PROV # FOR GROUP NAMED: METROPOLITAN MEDICAL CONSULTANTS, S.C.
IL208486OtherGROUP PROVIDER NUMBER FOR THE GROUP NAMED: CHICAGO UPTOWN MEDICAL CENTER, GROU
IL02215674OtherBCBC-IL GRP PROV # FOR GROUP NAMED: METROPOLITAN MEDICAL CONSULTANTS, S.C.
IL02215674OtherBCBC-IL GRP PROV # FOR GROUP NAMED: METROPOLITAN MEDICAL CONSULTANTS, S.C.
IL208486001Medicare PIN