Provider Demographics
NPI:1841340882
Name:FRESE, WILLIAM A (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:A
Last Name:FRESE
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 1:840 S WOOD ST
Mailing Address - Street 2:M/C 856
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4325
Mailing Address - Country:US
Mailing Address - Phone:312-413-1884
Mailing Address - Fax:312-413-0243
Practice Address - Street 1:1801 W TAYLOR ST
Practice Address - Street 2:SUITE 2E
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4795
Practice Address - Country:US
Practice Address - Phone:312-996-7416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2012-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI54693208000000X
IL036113073208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036113073Medicaid
WI1841340882Medicaid
WI736011823Medicare PIN