Provider Demographics
NPI:1801996368
Name:FRY, MARY ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:MARY
Middle Name:ELIZABETH
Last Name:FRY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2800 N SHERIDAN RD
Mailing Address - Street 2:STE 408
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657
Mailing Address - Country:US
Mailing Address - Phone:773-281-7711
Mailing Address - Fax:773-248-7556
Practice Address - Street 1:2800 N SHERIDAN RD STE 309
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657-6160
Practice Address - Country:US
Practice Address - Phone:773-248-6913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036064422207RA0401X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0360644Z2Medicaid
IL0360644Z2Medicaid
IL0360644Z2Medicaid
C44267Medicare UPIN