Provider Demographics
NPI:1861503153
Name:ASTHMA AND ALLERGY CENTER OF CHICAGO SC
Entity Type:Organization
Organization Name:ASTHMA AND ALLERGY CENTER OF CHICAGO SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:E
Authorized Official - Last Name:LISBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-366-9300
Mailing Address - Street 1:7420 CENTRAL AVE
Mailing Address - Street 2:SUITE 2020
Mailing Address - City:RIVER FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60305-1800
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7420 CENTRAL AVE
Practice Address - Street 2:SUITE 2020
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1800
Practice Address - Country:US
Practice Address - Phone:708-366-9300
Practice Address - Fax:708-366-9310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2009-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036067746207KA0200X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036067746Medicaid
IL31603461OtherBLUE CROSS BLUE SHIELD
IL31603461OtherBLUE CROSS BLUE SHIELD
IL31603461OtherBLUE CROSS BLUE SHIELD
IL919410Medicare ID - Type Unspecified