=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154721348
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH BRANCH DERMATOLOGY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/26/2014
-----------------------------------------------------
Last Update Date | 08/26/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7411 N MILWAUKEE AVE
-----------------------------------------------------
City | NILES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60714-3707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-763-6000
-----------------------------------------------------
Fax | 773-763-6006
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7411 N MILWAUKEE AVE
-----------------------------------------------------
City | NILES
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60714-3707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 773-763-6000
-----------------------------------------------------
Fax | 773-763-6006
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ELIZABETH N. FAHRENBACH
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 847-254-2193
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207N00000X
-----------------------------------------------------
Taxonomy Name | Dermatology Physician
-----------------------------------------------------
License Number | 036133358
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------