Provider Demographics
NPI:1609003557
Name:FAHRENBACH, ELIZABETH NORD (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:NORD
Last Name:FAHRENBACH
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 1:7411 N MILWAUKEE AVE
Mailing Address - Street 2:
Mailing Address - City:NILES
Mailing Address - State:IL
Mailing Address - Zip Code:60714-3707
Mailing Address - Country:US
Mailing Address - Phone:773-763-6000
Mailing Address - Fax:773-763-6000
Practice Address - Street 1:7411 N MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:IL
Practice Address - Zip Code:60714-3707
Practice Address - Country:US
Practice Address - Phone:773-763-6000
Practice Address - Fax:773-763-6000
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2022-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI60769-20207NI0002X, 207NP0225X, 207NS0135X, 207N00000X, 207ND0900X
IL125.056349207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NI0002XAllopathic & Osteopathic PhysiciansDermatologyClinical & Laboratory Dermatological Immunology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1609003557Medicaid
WI1609003557Medicaid