Healthcare Provider Details

I. General information

NPI: 1356321244
Provider Name (Legal Business Name): CHARLES FREY JR. DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 09/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

698 FEATHERSTONE RD
ROCKFORD IL
61107-6303
US

IV. Provider business mailing address

698 FEATHERSTONE RD
ROCKFORD IL
61107-6303
US

V. Phone/Fax

Practice location:
  • Phone: 815-398-3277
  • Fax: 815-484-7001
Mailing address:
  • Phone: 815-398-3277
  • Fax: 815-484-7001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number036063367
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number036063367
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: