Healthcare Provider Details

I. General information

NPI: 1528038718
Provider Name (Legal Business Name): FRED HARRY FISHER CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2006
Last Update Date: 06/09/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29W505 CERNY CIR
WARRENVILLE IL
60555-2516
US

IV. Provider business mailing address

PO BOX 5944
NAPERVILLE IL
60567-5944
US

V. Phone/Fax

Practice location:
  • Phone: 630-922-9881
  • Fax: 630-393-3732
Mailing address:
  • Phone: 630-393-3731
  • Fax: 630-393-3732

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number238.000008
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: