Provider Demographics
NPI:1558372995
Name:FABER, THEODORE T (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:T
Last Name:FABER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2045 W GRAND AVE STE B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-1577
Mailing Address - Country:US
Mailing Address - Phone:708-630-1534
Mailing Address - Fax:
Practice Address - Street 1:2045 W GRAND AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-1576
Practice Address - Country:US
Practice Address - Phone:086-301-5347
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC142762084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC142768Medicaid
SCE137269482OtherMEDICARE PTAN
SCE13726Medicare UPIN