Basic Information
Provider Information
NPI: 1316169949
EntityType: 2
ReplacementNPI:  
OrganizationName: ALEXIAN BROTHERS MEDICAL CENTER
LastName:  
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Credential:  
OtherOrganizationName:  
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Mailing Information
Address1: 800 BIESTERFIELD RD STE 605
Address2: EBERLE MEDICAL OFFICE BUILDING
City: ELK GROVE VILLAGE
State: IL
PostalCode: 600073362
CountryCode: US
TelephoneNumber: 7186446778
FaxNumber: 8473646720
Practice Location
Address1: 800 BIESTERFIELD RD STE 605
Address2: EBERLE MEDICAL OFFICE BUILDING
City: ELK GROVE VILLAGE
State: IL
PostalCode: 600073362
CountryCode: US
TelephoneNumber: 7186446778
FaxNumber: 8473646720
Other Information
ProviderEnumerationDate: 05/03/2007
LastUpdateDate: 07/18/2007
NPIDeactivationReasonCode:  
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ProviderGenderCode:  
AuthorizedOfficialLastName: FISHMAN
AuthorizedOfficialFirstName: ILYA
AuthorizedOfficialMiddleName: ISAAKOVICH
AuthorizedOfficialTitleorPosition: PHYSICIAN
AuthorizedOfficialTelephone: 7186446778
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: DR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: MD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
275N00000X243397NYY Hospital UnitsMedicare Defined Swing Bed Unit 

No ID Information.


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