Provider Demographics
NPI:1871726414
Name:E KENT FRYE MD SC
Entity type:Organization
Organization Name:E KENT FRYE MD SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER PFS
Authorized Official - Prefix:
Authorized Official - First Name:ANGIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HOUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-673-4603
Mailing Address - Street 1:908 PERCY CT
Mailing Address - Street 2:
Mailing Address - City:BOURBONNAIS
Mailing Address - State:IL
Mailing Address - Zip Code:60914-1884
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:104 W 6TH ST STE 206
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-2864
Practice Address - Country:US
Practice Address - Phone:815-672-7289
Practice Address - Fax:815-672-2891
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-31
Last Update Date:2010-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036081908208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1952392557OtherNPI