Provider Demographics
NPI:1386634525
Name:MARK FRITZ MD LTD
Entity Type:Organization
Organization Name:MARK FRITZ MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:FRITZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-741-0666
Mailing Address - Street 1:212 N LARKIN AVE
Mailing Address - Street 2:
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-6604
Mailing Address - Country:US
Mailing Address - Phone:815-741-0666
Mailing Address - Fax:815-741-0649
Practice Address - Street 1:212 N LARKIN AVE
Practice Address - Street 2:
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-6604
Practice Address - Country:US
Practice Address - Phone:815-741-0666
Practice Address - Fax:815-741-0649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-27
Last Update Date:2008-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36099618207W00000X
WI37999020207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036099618Medicaid
IL036099618Medicaid
IL4502860001Medicare NSC
G92740Medicare UPIN