Provider Demographics
NPI:1407219504
Name:ILLINOIS ADULT HEALTHCARE LLC
Entity Type:Organization
Organization Name:ILLINOIS ADULT HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:ILYA
Authorized Official - Middle Name:I
Authorized Official - Last Name:FISHMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-644-6778
Mailing Address - Street 1:800 BIESTERFIELD RD
Mailing Address - Street 2:SUITE 3007
Mailing Address - City:ELK GROVE VILLAGE
Mailing Address - State:IL
Mailing Address - Zip Code:60007-3361
Mailing Address - Country:US
Mailing Address - Phone:847-290-6513
Mailing Address - Fax:847-290-8505
Practice Address - Street 1:800 BIESTERFIELD RD
Practice Address - Street 2:SUITE 3007
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3361
Practice Address - Country:US
Practice Address - Phone:847-290-6513
Practice Address - Fax:847-290-8505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-04-05
Last Update Date:2016-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036118688207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty