Provider Demographics
NPI:1871528778
Name:FELLER, ALEXANDER ETHAN (MD)
Entity type:Individual
Prefix:DR
First Name:ALEXANDER
Middle Name:ETHAN
Last Name:FELLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 476705
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-6705
Mailing Address - Country:US
Mailing Address - Phone:773-307-8659
Mailing Address - Fax:
Practice Address - Street 1:19110 DARVIN DR
Practice Address - Street 2:
Practice Address - City:MOKENA
Practice Address - State:IL
Practice Address - Zip Code:60448-8595
Practice Address - Country:US
Practice Address - Phone:708-478-8889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2007-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09932287OtherBCBS
ILP00184861OtherRAILROAD MEDICARE
ILG24427Medicare UPIN
ILP00184861OtherRAILROAD MEDICARE