Provider Demographics
NPI:1467478404
Name:FREDRICK, MARK E (DC)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:FREDRICK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3930 WEST WASHINGTON STREET
Mailing Address - Street 2:STE B
Mailing Address - City:GURNEE
Mailing Address - State:IL
Mailing Address - Zip Code:60031-5702
Mailing Address - Country:US
Mailing Address - Phone:847-662-1600
Mailing Address - Fax:847-662-1612
Practice Address - Street 1:3930 WEST WASHINGTON STREET
Practice Address - Street 2:STE B
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-5702
Practice Address - Country:US
Practice Address - Phone:847-662-1600
Practice Address - Fax:847-662-1612
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-14
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038005092111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4915298OtherBCBS IL
IL906310Medicare PIN
T87778Medicare UPIN