Provider Demographics
NPI:1508034596
Name:FIFER, THEODORE D (MD FACS)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:D
Last Name:FIFER
Suffix:
Gender:M
Credentials:MD FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14900 N COURT 9
Mailing Address - Street 2:
Mailing Address - City:EFFINGHAM
Mailing Address - State:IL
Mailing Address - Zip Code:62401-7640
Mailing Address - Country:US
Mailing Address - Phone:217-994-6162
Mailing Address - Fax:217-342-7094
Practice Address - Street 1:14900 N COURT 9
Practice Address - Street 2:
Practice Address - City:EFFINGHAM
Practice Address - State:IL
Practice Address - Zip Code:62401-7640
Practice Address - Country:US
Practice Address - Phone:217-994-6162
Practice Address - Fax:217-342-7094
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-13
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360841362082S0105X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the Hand
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-084136Medicaid
IL025-00076OtherBLUE CROSS
972190Medicare PIN
IL025-00076OtherBLUE CROSS