Provider Demographics
NPI:1629095187
Name:FRALEY, EDITH (MD, FACEP)
Entity Type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:FRALEY
Suffix:
Gender:F
Credentials:MD, FACEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 REMITT DRIVE
Mailing Address - Street 2:LOCKBOX 1374
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60675-1374
Mailing Address - Country:US
Mailing Address - Phone:866-916-5259
Mailing Address - Fax:231-922-4030
Practice Address - Street 1:800 E CARPENTER ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62769-0002
Practice Address - Country:US
Practice Address - Phone:217-464-2966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT8340207P00000X
ARC-5539207P00000X
PAMD-041041-E207P00000X
NY168603207P00000X
OH35-047370207P00000X
IN01030295A207P00000X
NE15267207P00000X
IL207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B81799Medicare UPIN
ILL67829Medicare PIN
ILK35400Medicare PIN