MEDICARE: DR. FAE NOVA MD, PHD, MS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	125087495	IL

General Provider Information

NPI Number	:	1215878269
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. FAE NOVA MD, PHD, MS

Provider Business Mailing Address
First Line	:	180 HARVESTER DR STE 110
Second Line	:
City	:	BURR RIDGE
State	:	IL
Zip	:	60527-6686
Country	:	US
Telephone Number	:	773-702-1150
Fax Number	:

Provider Business Practice Location Address
First Line	:	5841 S MARYLAND AVE # 3077
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60637-1443
Country	:	US
Telephone Number	:	773-702-0529
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2026
Last Update Date	:	06/15/2026

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