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General NPI Number Information
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NPI Number | 1659467793
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Entity Type | Individual
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Provider Name | SHAWN M FRY M.D.
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Gender | Female
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Dates
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Enumeration Date | 10/05/2006
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Last Update Date | 12/11/2008
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Provider Practice Location Address
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Address Line | 610 N. WESTGATE
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City | JACKSONVILLE
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State | IL
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Zip | 62650
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Country | US
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Telephone | 217-245-9931
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Fax |
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Provider Business Mailing Address
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Address Line | 1025 S 6TH ST
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City | SPRINGFIELD
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State | IL
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Zip | 62703-2403
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Country | US
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Telephone | 217-528-7541
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 036-108501
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License Number State | IL
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