Provider Demographics
NPI:1053334862
Name:HENRETIG, FRED M (MD)
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:M
Last Name:HENRETIG
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:100 E PENN SQ
Mailing Address - Street 2:9TH FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-3323
Mailing Address - Country:US
Mailing Address - Phone:267-425-9234
Mailing Address - Fax:267-425-9299
Practice Address - Street 1:3401 CIVIC CENTER BLVD
Practice Address - Street 2:CHILDREN'S HOSPITAL OF PHILA - MEDICAL TOXICOLOGY
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19104-4319
Practice Address - Country:US
Practice Address - Phone:215-590-1944
Practice Address - Fax:215-590-4454
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2013-04-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
PAMD017526E208000000X, 2080P0204X, 2080T0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0204XAllopathic & Osteopathic PhysiciansPediatricsPediatric Emergency Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080T0002XAllopathic & Osteopathic PhysiciansPediatricsMedical Toxicology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3618501Medicaid
PA000764267Medicaid
NJ3618501Medicaid
PA000764267Medicaid