Healthcare Provider Details

I. General information

NPI: 1942289996
Provider Name (Legal Business Name): PETER D FRIES MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 10/28/2024
Certification Date: 10/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2160 S 1ST AVE
MAYWOOD IL
60153-3328
US

IV. Provider business mailing address

777 TANGLEFOOT LN
BETTENDORF IA
52722-1650
US

V. Phone/Fax

Practice location:
  • Phone: 708-216-9000
  • Fax:
Mailing address:
  • Phone: 563-323-2020
  • Fax: 563-328-5694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number036082456
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number28136
License Number StateIA
# 3
Primary TaxonomyN
Taxonomy Code207WX0200X
TaxonomyOphthalmic Plastic and Reconstructive Surgery Physician
License Number28136
License Number StateIA
# 4
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number036082456
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: