Basic Information
| Provider Information | |||||||||
| NPI: | 1396987277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREDERIKSEN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | KARL | ||||||||
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| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 840 S. WOOD ST. | ||||||||
| Address2: | 130 CSN M/C 847 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606124325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129967312 | ||||||||
| FaxNumber: | 3129967586 | ||||||||
| Practice Location | |||||||||
| Address1: | 840 S. WOOD ST. | ||||||||
| Address2: | 130 CSN M/C 847 | ||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606124325 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129967312 | ||||||||
| FaxNumber: | 3129967586 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2009 | ||||||||
| LastUpdateDate: | 08/31/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0102X | 036.158028 | IL | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
No ID Information.