Provider Demographics
NPI:1659538270
Name:EDWARD J FESCO MD SC
Entity Type:Organization
Organization Name:EDWARD J FESCO MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLO PRACTIONER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:FESCO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-223-3616
Mailing Address - Street 1:206 MARQUETTE ST
Mailing Address - Street 2:ROOM 218
Mailing Address - City:LASALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301
Mailing Address - Country:US
Mailing Address - Phone:815-223-3616
Mailing Address - Fax:815-223-0550
Practice Address - Street 1:206 MARQUETTE ST
Practice Address - Street 2:ROOM 206
Practice Address - City:LASALLE
Practice Address - State:IL
Practice Address - Zip Code:61301
Practice Address - Country:US
Practice Address - Phone:815-223-3616
Practice Address - Fax:815-223-0550
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EDWARD J FESCO MD SC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-21
Last Update Date:2008-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036034820208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL05000151OtherBC & BS
IL021757686OtherRR MED
IL036034820Medicaid
IL258640Medicare PIN
IL036034820Medicaid