Provider Demographics
NPI:1366450769
Name:KIST, FREDERICK OTTO
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:OTTO
Last Name:KIST
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1615 PHEASANT TRL
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:IL
Mailing Address - Zip Code:60067-4619
Mailing Address - Country:US
Mailing Address - Phone:847-358-6526
Mailing Address - Fax:847-358-6536
Practice Address - Street 1:1615 PHEASANT TRL
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:IL
Practice Address - Zip Code:60067-4619
Practice Address - Country:US
Practice Address - Phone:847-358-6526
Practice Address - Fax:847-358-6536
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor