Provider Demographics
NPI:1922066380
Name:FREDRICKSON, SARA JANE (MD)
Entity Type:Individual
Prefix:
First Name:SARA
Middle Name:JANE
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 N WINFIELD RD
Mailing Address - Street 2:
Mailing Address - City:WINFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:60190-1295
Mailing Address - Country:US
Mailing Address - Phone:630-307-7799
Mailing Address - Fax:630-307-2277
Practice Address - Street 1:25 N WINFIELD RD
Practice Address - Street 2:
Practice Address - City:WINFIELD
Practice Address - State:IL
Practice Address - Zip Code:60190-1295
Practice Address - Country:US
Practice Address - Phone:630-307-7799
Practice Address - Fax:630-307-2277
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2018-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360767582086X0206X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL4062703OtherAETNA
IL036076758Medicaid
IL206147220OtherMEDICARE (INDIVIDUAL PTAN)
IL2215516OtherBLUE CROSS BLUE SHIELD
IL036076758Medicaid
ILP12277Medicare PIN