Provider Demographics
NPI:1194829812
Name:FREDERICK MEDICAL CLINIC, PSC
Entity Type:Organization
Organization Name:FREDERICK MEDICAL CLINIC, PSC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATION MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:DENZIL
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:606-743-3114
Mailing Address - Street 1:PO BOX 607
Mailing Address - Street 2:
Mailing Address - City:WEST LIBERTY
Mailing Address - State:KY
Mailing Address - Zip Code:41472-0607
Mailing Address - Country:US
Mailing Address - Phone:606-743-3114
Mailing Address - Fax:606-743-1404
Practice Address - Street 1:430 LIBERTY RD
Practice Address - Street 2:
Practice Address - City:WEST LIBERTY
Practice Address - State:KY
Practice Address - Zip Code:41472-2049
Practice Address - Country:US
Practice Address - Phone:606-743-3114
Practice Address - Fax:606-743-1404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-12
Last Update Date:2014-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY183940261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100150550Medicaid
KY35002013Medicaid
KY183940Medicare Oscar/Certification
KYP100034165Medicare PIN
KY35002013Medicaid