Basic Information
| Provider Information | |||||||||
| NPI: | 1144290560 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREY | ||||||||
| FirstName: | KERE | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1740 W TAYLOR ST STE 3200 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606127232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129964037 | ||||||||
| FaxNumber: | 7082161249 | ||||||||
| Practice Location | |||||||||
| Address1: | 1740 W TAYLOR ST STE 3200 | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606127232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3129964037 | ||||||||
| FaxNumber: | 7082161249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 06/18/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/18/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 36084504 | IL | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 36084504 | 05 | IL | MEDICAID |