Provider Demographics
NPI:1245204312
Name:FAIRBROTHER, RICHARD J (DO)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:J
Last Name:FAIRBROTHER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 W ADDISON ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60618-6132
Mailing Address - Country:US
Mailing Address - Phone:773-404-1000
Mailing Address - Fax:773-404-9750
Practice Address - Street 1:2001 W ADDISON ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60618-6132
Practice Address - Country:US
Practice Address - Phone:773-404-1000
Practice Address - Fax:773-404-9750
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112340207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0361123401Medicaid
ILK19421Medicare ID - Type Unspecified
ILI35833Medicare UPIN