Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 036072388 | IL |
Y | 208600000X | Surgeon | 036072388 | IL |
NPI | 1023039674 |
---|---|
Provider Name | Dr. Howard Clark Federer III |
First Address | Chicago, IL 60625-3532 |
Second Address | Chicago, IL 60625-3500 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/07/2006 |
Last Update Date | 02/03/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036-072388 | (05) | IL |
406120103 | PTAN (01) | |
E76781 | (02) | IL |