Healthcare Provider Details

I. General information

NPI: 1750430104
Provider Name (Legal Business Name): FREDERICK R SPENCER DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 10/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

608 HILLGROVE AVE
WESTERN SPRINGS IL
60558-1476
US

IV. Provider business mailing address

1432 CALCUTTA LN
NAPERVILLE IL
60563-2215
US

V. Phone/Fax

Practice location:
  • Phone: 708-246-4591
  • Fax: 708-246-2086
Mailing address:
  • Phone: 708-246-4591
  • Fax: 708-246-2086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number016-003528
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: