Provider Demographics
NPI:1497712053
Name:FITZSIMONS, THERESE E (MD)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:E
Last Name:FITZSIMONS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1434 E EMMERSON LN STE 410
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-2604
Mailing Address - Country:US
Mailing Address - Phone:847-824-4282
Mailing Address - Fax:
Practice Address - Street 1:1415 MIDWAY LN STE 101
Practice Address - Street 2:
Practice Address - City:GLENVIEW
Practice Address - State:IL
Practice Address - Zip Code:60026-7739
Practice Address - Country:US
Practice Address - Phone:847-226-9070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-072028174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE60875Medicare UPIN
IL210189Medicare ID - Type Unspecified