Provider Demographics
NPI:1972519320
Name:LISBERG, EDWARD E (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:E
Last Name:LISBERG
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 1:1912 N LEAVITT ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-4409
Mailing Address - Country:US
Mailing Address - Phone:773-627-8737
Mailing Address - Fax:
Practice Address - Street 1:1912 N LEAVITT ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60647-4409
Practice Address - Country:US
Practice Address - Phone:773-627-8737
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067746207R00000X, 207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067746Medicaid
IL31603461OtherBC/BS PROVIDER #
IL363914202OtherTAX ID
IL31603461OtherBC/BS PROVIDER #
919410Medicare ID - Type UnspecifiedMEDICARE #