Provider Demographics
NPI:1467587949
Name:FRIBERG, WALTER (MD)
Entity Type:Individual
Prefix:
First Name:WALTER
Middle Name:
Last Name:FRIBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:293 WOODSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-6702
Mailing Address - Country:US
Mailing Address - Phone:847-459-8563
Mailing Address - Fax:
Practice Address - Street 1:4108 N SHERIDAN RD
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60613-2007
Practice Address - Country:US
Practice Address - Phone:773-529-4913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILI14948Medicare UPIN
ILK11568Medicare ID - Type Unspecified