Healthcare Provider Details

I. General information

NPI: 1346434578
Provider Name (Legal Business Name): ILYA ISAAKOVICH FISHMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 04/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 BIESTERFIELD RD EBERLE MEDICAL OFFICE BUILDING, SUITE 605
ELK GROVE VILLAGE IL
60007-3361
US

IV. Provider business mailing address

800 BIESTERFIELD RD SUITE 3007
ELK GROVE VILLAGE IL
60007-3361
US

V. Phone/Fax

Practice location:
  • Phone: 847-364-6724
  • Fax: 847-364-6720
Mailing address:
  • Phone: 847-290-6513
  • Fax: 847-290-8505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036.118688
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number036.118688
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: