Provider Demographics
NPI:1598247330
Name:FAZLIBASIC, STEPHANIE ANGELA
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANGELA
Last Name:FAZLIBASIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6400 SHAFER CT STE 300
Mailing Address - Street 2:
Mailing Address - City:ROSEMONT
Mailing Address - State:IL
Mailing Address - Zip Code:60018-4929
Mailing Address - Country:US
Mailing Address - Phone:800-570-8809
Mailing Address - Fax:
Practice Address - Street 1:6400 SHAFER CT STE 300
Practice Address - Street 2:
Practice Address - City:ROSEMONT
Practice Address - State:IL
Practice Address - Zip Code:60018-4929
Practice Address - Country:US
Practice Address - Phone:800-570-8809
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-29
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.017770207QH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QH0002XAllopathic & Osteopathic PhysiciansFamily MedicineHospice and Palliative MedicineGroup - Multi-Specialty