Healthcare Provider Details

I. General information

NPI: 1104919836
Provider Name (Legal Business Name): YASER B. FREIJ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 08/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N. MAIN
TAYLORVILLE IL
62568
US

IV. Provider business mailing address

1025 S 6TH ST
SPRINGFIELD IL
62703-2403
US

V. Phone/Fax

Practice location:
  • Phone: 217-287-8855
  • Fax:
Mailing address:
  • Phone: 217-528-7541
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036-046906
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: