Healthcare Provider Details

I. General information

NPI: 1003026048
Provider Name (Legal Business Name): DRS ROBIN & FRETZIN SC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 06/19/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41 S PROSPECT AVE
PARK RIDGE IL
60068-4138
US

IV. Provider business mailing address

41 S PROSPECT AVE
PARK RIDGE IL
60068-4138
US

V. Phone/Fax

Practice location:
  • Phone: 847-823-4113
  • Fax: 847-823-0059
Mailing address:
  • Phone: 847-823-4113
  • Fax: 847-823-0059

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036038658
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number036022673
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number036038658
License Number StateIL
# 4
Primary TaxonomyY
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number036038658
License Number StateIL
# 5
Primary TaxonomyN
Taxonomy Code207NS0135X
TaxonomyProcedural Dermatology Physician
License Number036022673
License Number StateIL

VIII. Authorized Official

Name: MRS. JILL SUTHERLAND
Title or Position: SUPERVISOR
Credential:
Phone: 847-459-6495