Provider Demographics
NPI:1376587626
Name:FRUMKIN, GARY (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:
Last Name:FRUMKIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5201 WILLOW SPRINGS RD
Mailing Address - Street 2:SUITE 160
Mailing Address - City:LAGRANGE
Mailing Address - State:IL
Mailing Address - Zip Code:60525
Mailing Address - Country:US
Mailing Address - Phone:708-354-0920
Mailing Address - Fax:708-354-0974
Practice Address - Street 1:3506 CLARK RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-8408
Practice Address - Country:US
Practice Address - Phone:941-299-0114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-065283207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL403270OtherGROUP PTAN
IL403270OtherGROUP PTAN
IL1617057OtherBLUE CROSS BLUE SHIELD
ILC42640Medicare UPIN
IL036065283-1Medicaid
ILP07331Medicare PIN
IL363300615OtherEIN