Provider Demographics
NPI:1972558567
Name:SCHUPP, ELIZABETH A (MD, FCCP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:A
Last Name:SCHUPP
Suffix:
Gender:F
Credentials:MD, FCCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 STATION DRIVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014
Mailing Address - Country:US
Mailing Address - Phone:815-477-7350
Mailing Address - Fax:815-477-7351
Practice Address - Street 1:4 EXECUTIVE CT
Practice Address - Street 2:SUITE 3
Practice Address - City:SOUTH BARRINGTON
Practice Address - State:IL
Practice Address - Zip Code:60010
Practice Address - Country:US
Practice Address - Phone:815-477-7350
Practice Address - Fax:815-477-7351
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036078246174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL127402OtherHEALTH ALLIANCE
IL3932056OtherBCBS
IL770669OtherHEALTHLINK
IL304906OtherGHP
IL036078246Medicaid
IL7210895OtherAETNA
ILE36990Medicare UPIN
IL036078246Medicaid
IL214881Medicare PIN
IL770669OtherHEALTHLINK