Healthcare Provider Details

I. General information

NPI: 1619328895
Provider Name (Legal Business Name): CRAIG FASSL ERBACH D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2016
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

IV. Provider business mailing address

4440 W 95TH ST
OAK LAWN IL
60453-2600
US

V. Phone/Fax

Practice location:
  • Phone: 708-684-5375
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number125.068921
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2019026354
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: