Healthcare Provider Details

I. General information

NPI: 1699960690
Provider Name (Legal Business Name): DOUGLAS JOHN FROHLICH I D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2007
Last Update Date: 11/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1229 N NORTH BRANCH ST SUITE 210
CHICAGO IL
60622-2473
US

IV. Provider business mailing address

1229 N NORTH BRANCH ST SUITE 210
CHICAGO IL
60642-2473
US

V. Phone/Fax

Practice location:
  • Phone: 312-939-5090
  • Fax:
Mailing address:
  • Phone: 312-939-5090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036074096
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number036-074096
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: