Provider Demographics
NPI:1295408573
Name:FISCHER, MADELINE R
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:R
Last Name:FISCHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MADELINE
Other - Middle Name:R
Other - Last Name:FRIEZE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:245 W ROOSEVELT RD STE 150
Mailing Address - Street 2:
Mailing Address - City:WEST CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60185-4818
Mailing Address - Country:US
Mailing Address - Phone:630-293-4124
Mailing Address - Fax:
Practice Address - Street 1:245 W ROOSEVELT RD STE 150
Practice Address - Street 2:
Practice Address - City:WEST CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60185-4818
Practice Address - Country:US
Practice Address - Phone:630-293-4124
Practice Address - Fax:630-293-9909
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-31
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL085008668363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program