Healthcare Provider Details

I. General information

NPI: 1538705272
Provider Name (Legal Business Name): BETHANY MAE FRISBY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2019
Last Update Date: 12/08/2021
Certification Date: 12/08/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8630 W GOLF RD
NILES IL
60714-5600
US

IV. Provider business mailing address

9701 W HIGGINS RD # 270
ROSEMONT IL
60018-4703
US

V. Phone/Fax

Practice location:
  • Phone: 847-299-0009
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number085.007344
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number085.007344
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: