Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208100000X | Physical Medicine & Rehabilitation Doctor | 036-102356 | IL |
N | 2081P2900X | Pain Medicine | 036-102356 | IL |
NPI | 1396750600 |
---|---|
Provider Name | Colleen Fitzgerald |
First Address | Maywood, IL 60153-3328 |
Second Address | Maywood, IL 60153-3328 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/07/2006 |
Last Update Date | 17/01/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
036102356 | (05) | IL |
H27562 | (02) | |
P00051933 | RAILROAD MEDICARE (01) | IL |
P00051934 | RR MEDICARE (01) | IL |