Basic Information
Provider Information | |||||||||
NPI: | 1316908049 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FRIED | ||||||||
FirstName: | ROBERT | ||||||||
MiddleName: | C | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 252 | ||||||||
Address2: |   | ||||||||
City: | BRYN MAWR | ||||||||
State: | PA | ||||||||
PostalCode: | 19010 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6104366529 | ||||||||
FaxNumber: | 6104366479 | ||||||||
Practice Location | |||||||||
Address1: | 255 W LANCASTER AVE | ||||||||
Address2: | MOB III SUITE 332 | ||||||||
City: | PAOLI | ||||||||
State: | PA | ||||||||
PostalCode: | 193011763 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6106473077 | ||||||||
FaxNumber: | 6109930668 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/31/2006 | ||||||||
LastUpdateDate: | 07/06/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD026594E | PA | Y |   | Allopathic & Osteopathic Physicians | Surgery |   |
ID Information
ID | Type | State | Issuer | Description | 0011072440002 | 05 | PA |   | MEDICAID |