1669453213 NPI number — JOHN RANDALL FREDERICK M.D.

Table of content: JOHN RANDALL FREDERICK M.D. (NPI 1669453213)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669453213 NPI number — JOHN RANDALL FREDERICK M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREDERICK
Provider First Name:
JOHN
Provider Middle Name:
RANDALL
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669453213
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/05/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1650 HUNTINGDON PIKE
Provider Second Line Business Mailing Address:
SUITE 154
Provider Business Mailing Address City Name:
MEADOWBROOK
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19046-8004
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
215-938-3145
Provider Business Mailing Address Fax Number:
215-938-3144

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1650 HUNTINGDON PIKE
Provider Second Line Business Practice Location Address:
SUITE 154
Provider Business Practice Location Address City Name:
MEADOWBROOK
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19046-8004
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-938-3145
Provider Business Practice Location Address Fax Number:
215-938-3144
Provider Enumeration Date:
11/10/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  M.D.032063E , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1886916-03 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com