Basic Information
Provider Information | |||||||||
NPI: | 1265478481 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ROYCE | ||||||||
FirstName: | FREDERICK | ||||||||
MiddleName: | HENRY | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: | JR. | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | ROYCE | ||||||||
OtherFirstName: | FRED | ||||||||
OtherMiddleName: | H | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 850 POPLAR AVE BLDG 2 | ||||||||
Address2: |   | ||||||||
City: | MEMPHIS | ||||||||
State: | TN | ||||||||
PostalCode: | 381054607 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9012875565 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3901 BEAUBIEN ST | ||||||||
Address2: |   | ||||||||
City: | DETROIT | ||||||||
State: | MI | ||||||||
PostalCode: | 482012119 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3137455437 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/22/2006 | ||||||||
LastUpdateDate: | 05/03/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/03/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0214X | 58146 | TN | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology | 2080P0214X | 4301500736 | MI | Y |   | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
ID | Type | State | Issuer | Description | 2254591 | 05 | OH |   | MEDICAID |