Provider Demographics
NPI:1134250095
Name:FISHER, ELYSA B
Entity type:Individual
Prefix:DR
First Name:ELYSA
Middle Name:B
Last Name:FISHER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3612 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-1000
Mailing Address - Country:US
Mailing Address - Phone:847-256-9400
Mailing Address - Fax:847-256-9412
Practice Address - Street 1:3612 LAKE AVE
Practice Address - Street 2:
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-1000
Practice Address - Country:US
Practice Address - Phone:847-256-9400
Practice Address - Fax:847-256-9412
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILE51726Medicare UPIN