Healthcare Provider Details

I. General information

NPI: 1760047096
Provider Name (Legal Business Name): TRISTAN BLASE FRIED MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 ALA MOANA BLVD STE 4-470
HONOLULU HI
96813-4925
US

IV. Provider business mailing address

1611 W HARRISON ST STE 201
CHICAGO IL
60612-4861
US

V. Phone/Fax

Practice location:
  • Phone: 808-909-9115
  • Fax:
Mailing address:
  • Phone: 312-563-6306
  • Fax: 312-942-2040

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License NumberMD-25682
License Number StateHI
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number036168181
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: