Healthcare Provider Details

I. General information

NPI: 1023040573
Provider Name (Legal Business Name): THOMAS L. FISHER, M.D., S.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47 W POLK ST LBBY G1
CHICAGO IL
60605-2087
US

IV. Provider business mailing address

47 W POLK ST LBBY G1
CHICAGO IL
60605-2087
US

V. Phone/Fax

Practice location:
  • Phone: 312-922-3011
  • Fax: 312-922-5875
Mailing address:
  • Phone: 312-922-3011
  • Fax: 312-922-5875

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: THOMAS L. FISHER, SR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 312-922-3011