Provider Demographics
NPI:1740227958
Name:FEDOROV, ALEXANDER (DC)
Entity Type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:
Last Name:FEDOROV
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 SHADOWBEND DR
Mailing Address - Street 2:
Mailing Address - City:WHEELING
Mailing Address - State:IL
Mailing Address - Zip Code:60090-3162
Mailing Address - Country:US
Mailing Address - Phone:847-840-8009
Mailing Address - Fax:
Practice Address - Street 1:7 N WOLF RD
Practice Address - Street 2:
Practice Address - City:PROSPECT HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60070-1749
Practice Address - Country:US
Practice Address - Phone:847-297-2225
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL38009253111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK06690Medicare ID - Type UnspecifiedCHIROPRACTIC