Basic Information
| Provider Information | |||||||||
| NPI: | 1669453213 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FREDERICK | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | RANDALL | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1650 HUNTINGDON PIKE | ||||||||
| Address2: | SUITE 154 | ||||||||
| City: | MEADOWBROOK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190468004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159383145 | ||||||||
| FaxNumber: | 2159383144 | ||||||||
| Practice Location | |||||||||
| Address1: | 1650 HUNTINGDON PIKE | ||||||||
| Address2: | SUITE 154 | ||||||||
| City: | MEADOWBROOK | ||||||||
| State: | PA | ||||||||
| PostalCode: | 190468004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159383145 | ||||||||
| FaxNumber: | 2159383144 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 01/05/2016 | ||||||||
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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 | 208600000X | M.D.032063E | PA | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1886916-03 | 05 | PA | MEDICAID |