Healthcare Provider Details

I. General information

NPI: 1679583520
Provider Name (Legal Business Name): MARVIN FREEDMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 08/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

277 SYLVAN RD
GLENCOE IL
60022-1225
US

IV. Provider business mailing address

277 SYLVAN RD
GLENCOE IL
60022-1225
US

V. Phone/Fax

Practice location:
  • Phone: 847-835-0277
  • Fax: 847-835-0277
Mailing address:
  • Phone: 847-835-0277
  • Fax: 847-835-0277

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number036035290
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: