Healthcare Provider Details

I. General information

NPI: 1861503153
Provider Name (Legal Business Name): ASTHMA AND ALLERGY CENTER OF CHICAGO SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7420 CENTRAL AVE SUITE 2020
RIVER FOREST IL
60305-1800
US

IV. Provider business mailing address

7420 CENTRAL AVE SUITE 2020
RIVER FOREST IL
60305-1800
US

V. Phone/Fax

Practice location:
  • Phone: 708-366-9300
  • Fax: 708-366-9310
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number036067746
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036067746
License Number StateIL

VIII. Authorized Official

Name: DR. EDWARD E LISBERG
Title or Position: DIRECTOR
Credential: MD
Phone: 708-366-9300