Basic Information
| Provider Information | |||||||||
| NPI: | 1366552762 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREDERICK | ||||||||
| FirstName: | KEITH | ||||||||
| MiddleName: | J. | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1050 W 10TH ST | ||||||||
| Address2: | ATTN: EXECUTIVE DIRECTOR OF PHYSICIAN CLINICS | ||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 65401 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5734583451 | ||||||||
| FaxNumber: | 5734262108 | ||||||||
| Practice Location | |||||||||
| Address1: | 1050 W 10TH ST | ||||||||
| Address2: | |||||||||
| City: | ROLLA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 654012905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5733645633 | ||||||||
| FaxNumber: | 5734265314 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/30/2006 | ||||||||
| LastUpdateDate: | 08/22/2019 | ||||||||
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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 | 207X00000X | R4D88 | MO | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 242256303 | 05 | MO | MEDICAID |