Provider Demographics
NPI:1699705962
Name:FEDIE, JUSTIN M (PT)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:M
Last Name:FEDIE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:630-575-7450
Practice Address - Street 1:555 E TOWNLINE RD STE 24
Practice Address - Street 2:
Practice Address - City:VERNON HILLS
Practice Address - State:IL
Practice Address - Zip Code:60061-1552
Practice Address - Country:US
Practice Address - Phone:847-573-0051
Practice Address - Fax:847-573-0345
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10260024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI40442300Medicaid
WI0604410001OtherDMERC
ILK15649Medicare ID - Type Unspecified
K15648Medicare ID - Type Unspecified
WI0604410001OtherDMERC