Healthcare Provider Details

I. General information

NPI: 1326232547
Provider Name (Legal Business Name): JESSICA TERESA FRY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DR. JESSICA TERESA CARNEY

II. Dates (important events)

Enumeration Date: 08/30/2007
Last Update Date: 09/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE # 45 ANN & ROBERT H LURIE CHILDREN'S HOSPITAL OF CHICAGO
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

225 E CHICAGO AVE # 45 ANN & ROBERT H LURIE CHILDREN'S HOSPITAL OF CHICAGO
CHICAGO IL
60611-2991
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-5277
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-121016
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: