Provider Demographics
NPI:1912018383
Name:ZEDIKER, PHILLIP LOREN (PH D)
Entity Type:Individual
Prefix:DR
First Name:PHILLIP
Middle Name:LOREN
Last Name:ZEDIKER
Suffix:
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 E NORTH ST STE B
Mailing Address - Street 2:
Mailing Address - City:BRADLEY
Mailing Address - State:IL
Mailing Address - Zip Code:60915-1186
Mailing Address - Country:US
Mailing Address - Phone:815-933-0667
Mailing Address - Fax:815-933-0665
Practice Address - Street 1:525 E NORTH ST STE B
Practice Address - Street 2:
Practice Address - City:BRADLEY
Practice Address - State:IL
Practice Address - Zip Code:60915-1186
Practice Address - Country:US
Practice Address - Phone:815-933-0667
Practice Address - Fax:815-933-0665
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071001596103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL481520Medicare ID - Type Unspecified