MEDICARE: ELISABETH FELLOWES

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	171100000X	Acupuncturist	198001426	IL

General Provider Information

NPI Number	:	1285108167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELISABETH FELLOWES

Provider Business Mailing Address
First Line	:	4753 N BROADWAY ST STE 821
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-6889
Country	:	US
Telephone Number	:	312-925-4177
Fax Number	:

Provider Business Practice Location Address
First Line	:	4753 N BROADWAY ST STE 821
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60640-6889
Country	:	US
Telephone Number	:	312-925-4177
Fax Number	:

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

Provider Enumeration Date	:	01/14/2019
Last Update Date	:	01/14/2019

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Directions to “ ELISABETH FELLOWES ” Practice Location

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