Provider Demographics
NPI:1730456914
Name:FISCHER, JUSTIN LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:LEE
Last Name:FISCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JUSTIN
Other - Middle Name:LEE
Other - Last Name:FISCHER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1001 MAIN ST
Mailing Address - Street 2:STE 300
Mailing Address - City:PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61606-2036
Mailing Address - Country:US
Mailing Address - Phone:309-495-0201
Mailing Address - Fax:309-676-6545
Practice Address - Street 1:1001 MAIN ST
Practice Address - Street 2:STE 300
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61606-2036
Practice Address - Country:US
Practice Address - Phone:309-495-0201
Practice Address - Fax:309-676-6545
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-16
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036139889208C00000X
IL36139889208C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208C00000XAllopathic & Osteopathic PhysiciansColon & Rectal SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36139889-1Medicaid