MEDICARE: SUSAN FEDINEC, D.O. LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261Q00000X	Clinic/Center	036 078573	IL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	9932303	OTHER	IL	BLUE CROSS BLUE SHIELD ID
2	036 078573	OTHER	IL	IL STATE LICENSE #

General Provider Information

NPI Number	:	1215007505
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUSAN FEDINEC, D.O. LLC

Provider Business Mailing Address
First Line	:	24600 W 127TH ST
Second Line	:	SUITE 340 BLDG B
City	:	PLAINFIELD
State	:	IL
Zip	:	60585-9507
Country	:	US
Telephone Number	:	815-676-2940
Fax Number	:	815-676-2942

Provider Business Practice Location Address
First Line	:	24600 W 127TH ST
Second Line	:	BLDG B SUITE 340
City	:	PLAINFIELD
State	:	IL
Zip	:	60585-9502
Country	:	US
Telephone Number	:	815-676-2940
Fax Number	:	815-676-2942

Authorized Official
Title or Position	:	OWNER
Name	:	DR. SUSAN MARIE FEDINEC
Credential	:	D.O.
Telephone Number	:	815-676-2940

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	07/29/2008

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