Provider Demographics
NPI:1003026048
Name:DRS ROBIN & FRETZIN SC
Entity Type:Organization
Organization Name:DRS ROBIN & FRETZIN SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JILL
Authorized Official - Middle Name:
Authorized Official - Last Name:SUTHERLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-459-6495
Mailing Address - Street 1:41 S PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:IL
Mailing Address - Zip Code:60068-4138
Mailing Address - Country:US
Mailing Address - Phone:847-823-4113
Mailing Address - Fax:847-823-0059
Practice Address - Street 1:41 S PROSPECT AVE
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:IL
Practice Address - Zip Code:60068-4138
Practice Address - Country:US
Practice Address - Phone:847-823-4113
Practice Address - Fax:847-823-0059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-22
Last Update Date:2012-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036038658207N00000X, 207ND0900X, 207NS0135X
IL036022673207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural DermatologyGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1891784401OtherFRETZIN NPI#
IL0001615219OtherDF BCBS PROV#
IL036038658OtherDF STATE LIC#
IL0001615219OtherDF BCBS PROV#
IL453460Medicare ID - Type UnspecifiedFRETZIN PIN#
IL070003505Medicare ID - Type UnspecifiedRR MC# FOR FRETZIN