Basic Information
Provider Information | |||||||||
NPI: | 1558347005 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BRANDITZ | ||||||||
FirstName: | FRED | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 945 BETHESDA DR STE 200 | ||||||||
Address2: |   | ||||||||
City: | ZANESVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 437011880 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7404544788 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 751 FOREST AVE STE 400 | ||||||||
Address2: |   | ||||||||
City: | ZANESVILLE | ||||||||
State: | OH | ||||||||
PostalCode: | 437012875 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7405866888 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/16/2005 | ||||||||
LastUpdateDate: | 07/24/2012 | ||||||||
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 | 207R00000X | 35055322 | OH | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RP1001X | 35-055322 | OH | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Pulmonary Disease |
ID Information
ID | Type | State | Issuer | Description | 110175445 | 01 | OH | MEDICARE RAILROAD | OTHER | CA1586 | 01 |   | GROUP MEDICARE RAILROAD | OTHER | 0669487 | 05 | OH |   | MEDICAID | 0989499 | 01 | OH | GROUP MEDICAID | OTHER |