Provider Demographics
NPI:1306813340
Name:FRY, TONY L (DC)
Entity type:Individual
Prefix:DR
First Name:TONY
Middle Name:L
Last Name:FRY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 N GUM ST
Mailing Address - Street 2:STE 3
Mailing Address - City:HARRISBURG
Mailing Address - State:IL
Mailing Address - Zip Code:62946
Mailing Address - Country:US
Mailing Address - Phone:618-252-5252
Mailing Address - Fax:
Practice Address - Street 1:101 N GUM ST
Practice Address - Street 2:STE 3
Practice Address - City:HARRISBURG
Practice Address - State:IL
Practice Address - Zip Code:62946-1567
Practice Address - Country:US
Practice Address - Phone:618-252-5252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-08
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008345111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL07222709OtherBLUE CROSS