Provider Demographics
NPI:1891781456
Name:FESCO, EDWARD JOHN (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:JOHN
Last Name:FESCO
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 1:206 MARQUETTE ST
Mailing Address - Street 2:ROOM 218
Mailing Address - City:LA SALLE
Mailing Address - State:IL
Mailing Address - Zip Code:61301-8863
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 218
Practice Address - City:LA SALLE
Practice Address - State:IL
Practice Address - Zip Code:61301-8863
Practice Address - Country:US
Practice Address - Phone:815-223-3616
Practice Address - Fax:815-223-0550
Is Sole Proprietor?:No
Enumeration Date:2005-09-20
Last Update Date:2008-08-25
Deactivation Date:2006-03-24
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
IL036034820208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036034820Medicaid
IL05000151OtherBCBS
IL021757686Medicare ID - Type UnspecifiedRR
C38431Medicare UPIN
IL258640Medicare ID - Type Unspecified