Basic Information
Provider Information | |||||||||
NPI: | 1902192156 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FRISKE | ||||||||
FirstName: | CASEY | ||||||||
MiddleName: | ROBERT | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | D.P.M. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1600 E GUDE DR | ||||||||
Address2: | SUITE 200 | ||||||||
City: | ROCKVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 208501341 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3019337133 | ||||||||
FaxNumber: | 3019337137 | ||||||||
Practice Location | |||||||||
Address1: | 6100 DAYLONG LN | ||||||||
Address2: | SUITE 208 | ||||||||
City: | CLARKSVILLE | ||||||||
State: | MD | ||||||||
PostalCode: | 210291626 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4435358770 | ||||||||
FaxNumber: | 4435358775 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/27/2011 | ||||||||
LastUpdateDate: | 11/28/2018 | ||||||||
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 | 213E00000X | 01532 | MD | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist |   |
ID Information
ID | Type | State | Issuer | Description | 235307500 | 05 | MD |   | MEDICAID |