Healthcare Provider Details

I. General information

NPI: 1073015269
Provider Name (Legal Business Name): MICHAEL MARTIN FISHKIN C.PED
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/02/2018
Last Update Date: 08/03/2026
Certification Date: 08/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 E TERRA COTTA AVE STE C
CRYSTAL LAKE IL
60014-3621
US

IV. Provider business mailing address

508 ABBEYWOOD DR
CARY IL
60013-2470
US

V. Phone/Fax

Practice location:
  • Phone: 847-639-5800
  • Fax:
Mailing address:
  • Phone: 847-915-0547
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224L00000X
TaxonomyPedorthist
License Number212.010327
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: