Provider Demographics
NPI:1578767935
Name:FABIAN CARBONELL MD SC
Entity Type:Organization
Organization Name:FABIAN CARBONELL MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:FABIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:CARBONELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-649-4261
Mailing Address - Street 1:331 W SURF ST STE 708
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-7227
Mailing Address - Country:US
Mailing Address - Phone:773-649-4261
Mailing Address - Fax:
Practice Address - Street 1:331 W SURF ST STE 708
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-7227
Practice Address - Country:US
Practice Address - Phone:773-649-4261
Practice Address - Fax:872-243-2843
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-12
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360980282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036098028Medicaid
IL595920Medicare ID - Type Unspecified