Healthcare Provider Details

I. General information

NPI: 1558719773
Provider Name (Legal Business Name): JORDAN A FRUCHEY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2016
Last Update Date: 05/23/2022
Certification Date: 05/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 N SAINT CLAIR ST STE 19-100
CHICAGO IL
60611-5969
US

IV. Provider business mailing address

675 N SAINT CLAIR ST STE 19-100
CHICAGO IL
60611-5969
US

V. Phone/Fax

Practice location:
  • Phone: 312-664-3278
  • Fax: 312-695-5774
Mailing address:
  • Phone: 312-664-3278
  • Fax: 312-695-5774

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085006365
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085006365
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: