Provider Demographics
NPI:1104861624
Name:FREDERICKS, CHARLES E (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:E
Last Name:FREDERICKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 VANTAGE WAY
Mailing Address - Street 2:SUITE B240
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37228-1515
Mailing Address - Country:US
Mailing Address - Phone:615-329-4020
Mailing Address - Fax:615-327-4403
Practice Address - Street 1:2000 CHURCH ST
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37236-0001
Practice Address - Country:US
Practice Address - Phone:800-251-2014
Practice Address - Fax:615-284-3854
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN28703207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3062222OtherBLUECROSS
TN3110235OtherSTONES RIVER IPA
KY64028434OtherKY MEDICAID
TN3816000Medicaid
KY64028434OtherKY MEDICAID
TN3816001Medicare ID - Type Unspecified