Provider Demographics
NPI:1699768739
Name:FISHER, MARK STEVEN (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:STEVEN
Last Name:FISHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2151 WAUKEGAN RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BANNOCKBURN
Mailing Address - State:IL
Mailing Address - Zip Code:60015-1885
Mailing Address - Country:US
Mailing Address - Phone:847-236-1300
Mailing Address - Fax:847-236-9549
Practice Address - Street 1:2151 WAUKEGAN RD
Practice Address - Street 2:SUITE 110
Practice Address - City:BANNOCKBURN
Practice Address - State:IL
Practice Address - Zip Code:60015-1885
Practice Address - Country:US
Practice Address - Phone:847-236-1300
Practice Address - Fax:847-236-9549
Is Sole Proprietor?:No
Enumeration Date:2005-08-24
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036063754207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036063754Medicaid
IL36-3200051OtherFEIN
IL36-3200051OtherFEIN