Basic Information
Provider Information | |||||||||
NPI: | 1417113069 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FISHBEIN | ||||||||
FirstName: | ANNA | ||||||||
MiddleName: | B | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD, MSC | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 225 E CHICAGO AVE # 60 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606112991 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3122276010 | ||||||||
FaxNumber: | 3122279401 | ||||||||
Practice Location | |||||||||
Address1: | 225 E CHICAGO AVE # 60 | ||||||||
Address2: |   | ||||||||
City: | CHICAGO | ||||||||
State: | IL | ||||||||
PostalCode: | 606112991 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3122276010 | ||||||||
FaxNumber: | 3122279401 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2008 | ||||||||
LastUpdateDate: | 11/18/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 125052680 | IL | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080P0214X | D74340 | MD | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology | 208000000X | D74340 | MD | N |   | Allopathic & Osteopathic Physicians | Pediatrics |   |
ID Information
ID | Type | State | Issuer | Description | 202402100 | 05 | MD |   | MEDICAID |