Provider Demographics
NPI:1144202953
Name:RADKE, FREDERICK ROY (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:ROY
Last Name:RADKE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301C US ROUTE 1
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:887 CONGRESS ST
Practice Address - Street 2:SUITE 400
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3100
Practice Address - Country:US
Practice Address - Phone:207-774-6368
Practice Address - Fax:207-662-7996
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD10664208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30203950Medicaid
MEP00384070OtherRR MEDICARE
ME113290099Medicaid
ME01503901Medicare PIN
MEHX4811Medicare PIN
ME01503902Medicare PIN
B86510Medicare UPIN