Provider Demographics
NPI:1396915955
Name:ELISABETH I. WALLNER, M.D., S.C.
Entity type:Organization
Organization Name:ELISABETH I. WALLNER, M.D., S.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ELISABETH
Authorized Official - Middle Name:I
Authorized Official - Last Name:WALLNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:312-926-0888
Mailing Address - Street 1:676 N ST CLAIR
Mailing Address - Street 2:SUITE 2250
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-0075
Mailing Address - Country:US
Mailing Address - Phone:312-926-0888
Mailing Address - Fax:312-926-0889
Practice Address - Street 1:676 N ST CLAIR
Practice Address - Street 2:SUITE 2250
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611
Practice Address - Country:US
Practice Address - Phone:312-926-0888
Practice Address - Fax:312-926-0889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-10
Last Update Date:2012-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36089720261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL001627372OtherBLUE CROSS BLUE SHIELD
IL9750416OtherCIGNA
IL036089720Medicaid
IL001627372OtherBLUE CROSS BLUE SHIELD
G07589Medicare UPIN