Healthcare Provider Details

I. General information

NPI: 1912902404
Provider Name (Legal Business Name): ROBERT KENNETH FRYZEK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/20/2005
Last Update Date: 03/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

PO BOX 69
GLENWOOD IA
51534-0069
US

IV. Provider business mailing address

14 N WALNUT ST
GLENWOOD IA
51534-1739
US

V. Phone/Fax

Practice location:
  • Phone: 712-527-9135
  • Fax: 712-527-5679
Mailing address:
  • Phone: 712-527-9135
  • Fax: 712-527-5679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number16752
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: