Provider Demographics
NPI:1952392557
Name:FRYE, EDWARD KENT (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:KENT
Last Name:FRYE
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 1:455 W COURT ST
Mailing Address - Street 2:STE 403
Mailing Address - City:KANKAKEE
Mailing Address - State:IL
Mailing Address - Zip Code:60901-3679
Mailing Address - Country:US
Mailing Address - Phone:815-939-3190
Mailing Address - Fax:815-935-5101
Practice Address - Street 1:455 W COURT ST
Practice Address - Street 2:STE 403
Practice Address - City:KANKAKEE
Practice Address - State:IL
Practice Address - Zip Code:60901-3679
Practice Address - Country:US
Practice Address - Phone:815-939-3190
Practice Address - Fax:815-935-5101
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081908208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL03081908Medicaid
ILIL1789OtherMEDICARE GROUP PTAN
ILIL1789002OtherMEDICARE PTAN
IL4600208OtherBLUE CROSS BLUE SHIELD
IL03081908Medicaid
ILIL1789OtherMEDICARE GROUP PTAN
IL4600208OtherBLUE CROSS BLUE SHIELD
ILL28010Medicare UPIN
IL340006926Medicare ID - Type UnspecifiedRAILROAD MEDICARE