Basic Information
| Provider Information | |||||||||
| NPI: | 1255821120 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BIREN-FETZ | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | |||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1740 W TAYLOR ST # MC931 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606127232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129968143 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1740 W TAYLOR ST # MC931 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606127232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129960235 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/15/2018 | ||||||||
| LastUpdateDate: | 04/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | R3011 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | 125.074472 | IL | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
ID Information
| ID | Type | State | Issuer | Description | 1255821120 | 05 | AZ | MEDICAID |