Healthcare Provider Details

I. General information

NPI: 1356382261
Provider Name (Legal Business Name): DANNY JOE FRIDAY PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

507 WASHINGTON ST
BEARDSTOWN IL
62618-1558
US

IV. Provider business mailing address

507 WASHINGTON ST
BEARDSTOWN IL
62618-1558
US

V. Phone/Fax

Practice location:
  • Phone: 217-323-2245
  • Fax: 217-323-1276
Mailing address:
  • Phone: 217-323-2245
  • Fax: 217-323-1276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: