Provider Demographics
NPI:1194802835
Name:WILLOW OAK PEDIATRICS
Entity type:Organization
Organization Name:WILLOW OAK PEDIATRICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:H
Authorized Official - Last Name:FISHER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-362-2500
Mailing Address - Street 1:1900 HOLLISTER DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:LIBERTYVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60048-5233
Mailing Address - Country:US
Mailing Address - Phone:847-362-2500
Mailing Address - Fax:847-362-5151
Practice Address - Street 1:1900 HOLLISTER DR
Practice Address - Street 2:SUITE 330
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-5233
Practice Address - Country:US
Practice Address - Phone:847-362-2500
Practice Address - Fax:847-362-5151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2007-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD15615Medicare UPIN