Provider Demographics
NPI:1922009943
Name:FEDDER, MARK STEPHEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:STEPHEN
Last Name:FEDDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6810 STATE ROUTE 162
Mailing Address - Street 2:SUITE 211
Mailing Address - City:MARYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62062-8501
Mailing Address - Country:US
Mailing Address - Phone:618-288-0346
Mailing Address - Fax:618-288-0349
Practice Address - Street 1:6810 STATE ROUTE 162
Practice Address - Street 2:SUITE 211
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-8501
Practice Address - Country:US
Practice Address - Phone:618-288-0346
Practice Address - Fax:618-288-0349
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2020-12-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IL036-067702207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE18658Medicare UPIN
IL551410Medicare ID - Type Unspecified