Provider Demographics
NPI:1659373165
Name:LEVY, FREDRIC JEROME (MD)
Entity Type:Individual
Prefix:DR
First Name:FREDRIC
Middle Name:JEROME
Last Name:LEVY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 E WACKER DR
Mailing Address - Street 2:SUITE 630
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60601-1802
Mailing Address - Country:US
Mailing Address - Phone:312-670-2590
Mailing Address - Fax:312-644-8183
Practice Address - Street 1:1 E WACKER DR
Practice Address - Street 2:SUITE 630
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60601-1802
Practice Address - Country:US
Practice Address - Phone:312-670-2590
Practice Address - Fax:312-644-8183
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36467172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILD12700Medicare UPIN
IL475970Medicare ID - Type Unspecified