Provider Demographics
NPI:1902393465
Name:FRATMISHIN J. ALEXANDER
Entity type:Organization
Organization Name:FRATMISHIN J. ALEXANDER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AUGANIA
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:ALEXANDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-338-6565
Mailing Address - Street 1:PO BOX 597770
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60659-7770
Mailing Address - Country:US
Mailing Address - Phone:773-338-6565
Mailing Address - Fax:773-338-6552
Practice Address - Street 1:6408 N CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60645-5209
Practice Address - Country:US
Practice Address - Phone:773-338-6565
Practice Address - Fax:773-338-6552
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-19
Last Update Date:2018-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1001041Medicaid