Provider Demographics
NPI:1003270331
Name:FRY, PHILLIP EDWARD JR (DO)
Entity Type:Individual
Prefix:
First Name:PHILLIP
Middle Name:EDWARD
Last Name:FRY
Suffix:JR
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:PHILLIP
Other - Middle Name:EDWARD
Other - Last Name:FRY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DO
Mailing Address - Street 1:3 EVERGLADE CT
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-3485
Mailing Address - Country:US
Mailing Address - Phone:575-420-3425
Mailing Address - Fax:
Practice Address - Street 1:20201 CRAWFORD AVE
Practice Address - Street 2:ATTN: POSTDOCTORAL EDUCATION
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461-1010
Practice Address - Country:US
Practice Address - Phone:708-747-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-12
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program