Healthcare Provider Details

I. General information

NPI: 1609003557
Provider Name (Legal Business Name): ELIZABETH NORD FAHRENBACH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2009
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7411 N MILWAUKEE AVE
NILES IL
60714-3707
US

IV. Provider business mailing address

7411 N MILWAUKEE AVE
NILES IL
60714-3707
US

V. Phone/Fax

Practice location:
  • Phone: 773-763-6000
  • Fax: 773-763-6000
Mailing address:
  • Phone: 773-763-6000
  • Fax: 773-763-6000

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number60769-20
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number60769-20
License Number StateWI
# 3
Primary TaxonomyN
Taxonomy Code207NI0002X
TaxonomyClinical & Laboratory Dermatological Immunology Physician
License Number60769-20
License Number StateWI
# 4
Primary TaxonomyN
Taxonomy Code207NP0225X
TaxonomyPediatric Dermatology Physician
License Number60769-20
License Number StateWI
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number60769-20
License Number StateWI
# 6
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number125.056349
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: