Healthcare Provider Details

I. General information

NPI: 1336388586
Provider Name (Legal Business Name): FABIOLLA SIQUEIRA KOPP MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/11/2009
Last Update Date: 12/03/2025
Certification Date: 12/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 N MICHIGAN AVE STE 506
CHICAGO IL
60602-3837
US

IV. Provider business mailing address

30 N MICHIGAN AVE STE 506
CHICAGO IL
60602-3837
US

V. Phone/Fax

Practice location:
  • Phone: 773-312-4423
  • Fax: 773-312-4522
Mailing address:
  • Phone: 773-312-4423
  • Fax: 773-312-4522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number036147419
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License NumberQ5683
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: