Provider Demographics
NPI:1174785588
Name:BLACHUT, TINA FRUSCIONE (DO)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:FRUSCIONE
Last Name:BLACHUT
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:JOSIE
Other - Last Name:FRUSCIONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:150 N RIVER RD STE 310
Mailing Address - Street 2:
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-1272
Mailing Address - Country:US
Mailing Address - Phone:847-795-0900
Mailing Address - Fax:847-795-0955
Practice Address - Street 1:150 N RIVER RD STE 310
Practice Address - Street 2:
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-1272
Practice Address - Country:US
Practice Address - Phone:847-795-0900
Practice Address - Fax:847-795-0955
Is Sole Proprietor?:No
Enumeration Date:2008-06-26
Last Update Date:2012-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036128628207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program