Healthcare Provider Details

I. General information

NPI: 1427073543
Provider Name (Legal Business Name): THOMAS LEE FISHER SR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 08/09/2022
Certification Date: 07/29/2022
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 Number036-043966
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number036-043966
License Number StateIL
# 3
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036-043966
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: