Healthcare Provider Details

I. General information

NPI: 1083795538
Provider Name (Legal Business Name): DR. WILLIAM THOMAS FADER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3860 W OGDEN AVE
CHICAGO IL
60623-2460
US

IV. Provider business mailing address

3860 W OGDEN AVE
CHICAGO IL
60623-2460
US

V. Phone/Fax

Practice location:
  • Phone: 773-843-3601
  • Fax: 773-843-2704
Mailing address:
  • Phone: 773-843-3601
  • Fax: 773-843-2704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036-072330
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: