Provider Demographics
NPI:1710984174
Name:FRIED, RICHARD GARY (DC)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:GARY
Last Name:FRIED
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1715 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOLINE
Mailing Address - State:IL
Mailing Address - Zip Code:61265-7911
Mailing Address - Country:US
Mailing Address - Phone:309-762-1050
Mailing Address - Fax:309-762-1064
Practice Address - Street 1:1715 5TH AVE
Practice Address - Street 2:
Practice Address - City:MOLINE
Practice Address - State:IL
Practice Address - Zip Code:61265-7911
Practice Address - Country:US
Practice Address - Phone:309-762-1050
Practice Address - Fax:309-762-1064
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-30
Last Update Date:2023-10-23
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
IL038005386111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038005386Medicaid
ILT38453Medicare UPIN