MEDICARE: DR. EDWARD E LISBERG MD

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	207R00000X	Internal Medicine Physician	036067746	IL
2	207KA0200X	Allergy Physician	036067746	IL

General Provider Information

NPI Number	:	1972519320
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EDWARD E LISBERG MD

Provider Business Mailing Address
First Line	:	1912 N LEAVITT ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-4409
Country	:	US
Telephone Number	:	773-627-8737
Fax Number	:

Provider Business Practice Location Address
First Line	:	1912 N LEAVITT ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60647-4409
Country	:	US
Telephone Number	:	773-627-8737
Fax Number	:

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

Provider Enumeration Date	:	07/31/2006
Last Update Date	:	04/22/2020

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