Provider Demographics
NPI:1700939535
Name:BRUCE FRAZIN MDSC
Entity Type:Organization
Organization Name:BRUCE FRAZIN MDSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:FRAZIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:847-249-0850
Mailing Address - Street 1:1616 GRAND AVENUE
Mailing Address - Street 2:SUITE A
Mailing Address - City:WAUKEGAN
Mailing Address - State:IL
Mailing Address - Zip Code:60085
Mailing Address - Country:US
Mailing Address - Phone:847-249-0850
Mailing Address - Fax:847-623-0505
Practice Address - Street 1:1616 GRAND AVENUE
Practice Address - Street 2:
Practice Address - City:WAUKEGAN
Practice Address - State:IL
Practice Address - Zip Code:60085
Practice Address - Country:US
Practice Address - Phone:847-249-0850
Practice Address - Fax:847-623-0505
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL03639794207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILC38294Medicare UPIN
IL246830Medicare PIN