Basic Information
| Provider Information | |||||||||
| NPI: | 1669436911 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FRANKENBERG | ||||||||
| FirstName: | FRED | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | II | ||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 DATES DR | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148501342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072744011 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 101 DATES DR | ||||||||
| Address2: | |||||||||
| City: | ITHACA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 148501342 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6072744011 | ||||||||
| FaxNumber: | 6072744198 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2006 | ||||||||
| LastUpdateDate: | 07/09/2013 | ||||||||
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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 | 208M00000X | 267226 | NY | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 266291400 | 05 | FL | MEDICAID | 364516922 | 01 | FL | TAX IDENTIFICATION | OTHER | 57648 | 01 | FL | BLUE CROSS BLUE SHIELD | OTHER | ME86861 | 01 | FL | STATE MEDICAL LICENSE | OTHER |