Provider Demographics
NPI:1134137417
Name:WOHLBERG, FREDERICK EDWARD (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDERICK
Middle Name:EDWARD
Last Name:WOHLBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:9760 S KEDZIE AVE
Mailing Address - Street 2:SUITE 6
Mailing Address - City:EVERGREEN PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60805-3109
Mailing Address - Country:US
Mailing Address - Phone:708-425-0112
Mailing Address - Fax:708-425-2785
Practice Address - Street 1:9760 S KEDZIE AVE
Practice Address - Street 2:SUITE 6
Practice Address - City:EVERGREEN PARK
Practice Address - State:IL
Practice Address - Zip Code:60805-3109
Practice Address - Country:US
Practice Address - Phone:708-425-0112
Practice Address - Fax:708-425-2785
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-042626208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
K20413Medicare PIN
214706015Medicare PIN
ILC42057Medicare UPIN