Basic Information
| Provider Information | |||||||||
| NPI: | 1104861624 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREDERICKS | ||||||||
| FirstName: | CHARLES | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 VANTAGE WAY | ||||||||
| Address2: | SUITE B240 | ||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372281515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6153294020 | ||||||||
| FaxNumber: | 6153274403 | ||||||||
| Practice Location | |||||||||
| Address1: | 2000 CHURCH ST | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372360001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8002512014 | ||||||||
| FaxNumber: | 6152843854 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2006 | ||||||||
| LastUpdateDate: | 06/10/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 28703 | TN | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3062222 | 01 | TN | BLUECROSS | OTHER | 3110235 | 01 | TN | STONES RIVER IPA | OTHER | 64028434 | 01 | KY | KY MEDICAID | OTHER | 3816000 | 05 | TN | MEDICAID |