Provider Demographics
NPI:1740220193
Name:FAIBUSSOWITSCH, ILJA (MD)
Entity Type:Individual
Prefix:
First Name:ILJA
Middle Name:
Last Name:FAIBUSSOWITSCH
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 1:2800 N SHERIDAN RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657-6156
Mailing Address - Country:US
Mailing Address - Phone:773-935-5556
Mailing Address - Fax:
Practice Address - Street 1:2800 N SHERIDAN RD
Practice Address - Street 2:SUITE 301
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6156
Practice Address - Country:US
Practice Address - Phone:773-935-5556
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2018-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ55021207RC0200X, 207RP1001X, 207RS0012X
IL036094678207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036094678Medicaid
IL036094678Medicaid