Provider Demographics
NPI:1851490148
Name:FRASER, MALCOLM (PT)
Entity Type:Individual
Prefix:
First Name:MALCOLM
Middle Name:
Last Name:FRASER
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 W WACKER DR
Mailing Address - Street 2:SUITE 1020
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60606-1216
Mailing Address - Country:US
Mailing Address - Phone:312-640-0329
Mailing Address - Fax:
Practice Address - Street 1:3430 GRAND AVE
Practice Address - Street 2:SUITE 400
Practice Address - City:GURNEE
Practice Address - State:IL
Practice Address - Zip Code:60031-3741
Practice Address - Country:US
Practice Address - Phone:847-782-9860
Practice Address - Fax:847-782-9866
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070008407225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist