Provider Demographics
NPI:1417181116
Name:CONCEPCION, FREDERMAN (MD)
Entity Type:Individual
Prefix:
First Name:FREDERMAN
Middle Name:
Last Name:CONCEPCION
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 1:2740 W FOSTER AVE
Mailing Address - Street 2:STE 310
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60625-3547
Mailing Address - Country:US
Mailing Address - Phone:773-878-8200
Mailing Address - Fax:773-293-4197
Practice Address - Street 1:5140 N CALIFORNIA AVE STE 780
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60625-7066
Practice Address - Country:US
Practice Address - Phone:773-989-3957
Practice Address - Fax:773-989-3971
Is Sole Proprietor?:No
Enumeration Date:2009-05-08
Last Update Date:2021-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114474207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036114474Medicaid
406120090OtherPTAN