Provider Demographics
NPI:1760047096
Name:FRIED, TRISTAN BLASE (MD)
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:BLASE
Last Name:FRIED
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1611 W HARRISON ST STE 201
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-4861
Mailing Address - Country:US
Mailing Address - Phone:312-563-6306
Mailing Address - Fax:312-942-2040
Practice Address - Street 1:1611 W HARRISON ST STE 201
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-4861
Practice Address - Country:US
Practice Address - Phone:312-563-6306
Practice Address - Fax:312-942-2040
Is Sole Proprietor?:No
Enumeration Date:2019-05-02
Last Update Date:2024-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA390200000X
IL036168181207XS0117X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program