Provider Demographics
NPI:1912919440
Name:WALLNER, ELISABETH I (MD, MPH)
Entity Type:Individual
Prefix:MS
First Name:ELISABETH
Middle Name:I
Last Name:WALLNER
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 11075
Mailing Address - Street 2:
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 SAINT CLAIR ST
Practice Address - Street 2:SUITE 2250
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2927
Practice Address - Country:US
Practice Address - Phone:312-926-0888
Practice Address - Fax:312-926-0889
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-13
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36089720207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL9750416OtherCIGNA HEALTHCARE
IL036089720Medicaid
IL001627372OtherBLUE CROSS BLUE SHIELD
IL601030Medicare ID - Type Unspecified
IL9750416OtherCIGNA HEALTHCARE