Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207RE0101X | Endocrinologist (Diabetes Doctor) | IL |
NPI | 1033179940 |
---|---|
Provider Name | Fredrick M Ellyin |
First Address | Chicago, IL 60625-3645 |
Second Address | Chicago, IL 60625-3645 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 24/03/2006 |
Last Update Date | 09/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
21609026 | BLUE SHIELD IL PROVIDER # (01) | IL |
C44980 | (02) | IL |