Basic Information
| Provider Information | |||||||||
| NPI: | 1710074653 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONDAHN | ||||||||
| FirstName: | DEAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 5009 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370245009 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152213642 | ||||||||
| FaxNumber: | 6153714600 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 E MILLER RD | ||||||||
| Address2: | |||||||||
| City: | STERLING | ||||||||
| State: | IL | ||||||||
| PostalCode: | 610811252 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8156254790 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 12/03/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208800000X | 036066790 | IL | Y | Allopathic & Osteopathic Physicians | Urology |
ID Information
| ID | Type | State | Issuer | Description | 012794 | 01 | IL | HEALTH ALLIANCE MEDICAL | OTHER | 036066790 | 05 | IL | MEDICAID | 9815737 | 01 | IL | BLUE CROSS BLUE SHIELD | OTHER | 340007312 | 01 | RAILROAD | OTHER |