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General NPI Number Information
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NPI Number | 1154616548
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Entity Type | Individual
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Provider Name | ROBERT FONG II MD, PHD
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Gender | Male
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Dates
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Enumeration Date | 06/14/2011
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Last Update Date | 06/14/2011
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Provider Practice Location Address
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Address Line | 5840 S MARYLAND AVE MC4028
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City | CHICAGO
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State | IL
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Zip | 60637-1462
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Country | US
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Telephone | 773-702-6700
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Fax |
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Provider Business Mailing Address
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Address Line | 9434 KOLMAR AVE
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City | SKOKIE
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State | IL
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Zip | 60076-1322
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Country | US
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Telephone | 773-575-3602
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207L00000X
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Taxonomy Name | Anesthesiology Physician
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License Number | 125.056492
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License Number State | IL
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