Basic Information
| Provider Information | |||||||||
| NPI: | 1396236402 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRICK | ||||||||
| FirstName: | WILLIAM | ||||||||
| MiddleName: | HARRY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 N GRAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631032006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3149772401 | ||||||||
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| Practice Location | |||||||||
| Address1: | 621 S NEW BALLAS RD | ||||||||
| Address2: | |||||||||
| City: | SAINT LOUIS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 631418232 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3142516339 | ||||||||
| FaxNumber: | 3142514564 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2018 | ||||||||
| LastUpdateDate: | 06/02/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | 11019891A | IN | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 2021017726 | MO | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 11019891A | 01 | IN | INDIANA PROFESSIONAL LICENSING AGENCY | OTHER |