Healthcare Provider Details

I. General information

NPI: 1073178240
Provider Name (Legal Business Name): RUSSELL HERBERG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2019
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W SUPERIOR ST STE 300
CHICAGO IL
60654-5563
US

IV. Provider business mailing address

200 W SUPERIOR ST STE 300
CHICAGO IL
60654-5563
US

V. Phone/Fax

Practice location:
  • Phone: 773-327-6800
  • Fax: 773-327-6877
Mailing address:
  • Phone: 773-327-6800
  • Fax: 773-327-6877

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number036.178604
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: