Healthcare Provider Details

I. General information

NPI: 1861475964
Provider Name (Legal Business Name): GREGORY J FAHRENBACH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/22/2005
Last Update Date: 02/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7447 W TALCOTT AVE SUITE 500 NORTHWEST ORTHOPAEDIC ASSOCIATES LTD
CHICAGO IL
60631-3745
US

IV. Provider business mailing address

7447 W TALCOTT AVE SUITE 500 NORTHWEST ORTHOPAEDIC ASSOCIATES LTD
CHICAGO IL
60631-3745
US

V. Phone/Fax

Practice location:
  • Phone: 773-631-7898
  • Fax: 773-631-3005
Mailing address:
  • Phone: 773-631-7898
  • Fax: 773-631-3005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XX0801X
TaxonomyOrthopaedic Trauma Physician
License Number036062547
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: