Provider Demographics
NPI:1285671065
Name:FREDERICK, ROBERT WINSTON (MD)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:WINSTON
Last Name:FREDERICK
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 1:833 CHESTNUT ST STE 520
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4430
Mailing Address - Country:US
Mailing Address - Phone:800-321-9999
Mailing Address - Fax:267-339-3761
Practice Address - Street 1:600 EVERGREEN DR STE 201
Practice Address - Street 2:
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-1053
Practice Address - Country:US
Practice Address - Phone:267-339-3558
Practice Address - Fax:267-339-3763
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2022-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06942500207XX0005X
MA73829207XX0005X
PAMD068498L207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2170578OtherAETNA
NJ0440582000OtherIBC
NJ2378262OtherAETNA
PA0819217000OtherIBC
2781249OtherCIGNA
2781249OtherCIGNA
NJ200043283Medicare PIN
NJ0440582000OtherIBC
PA2170578OtherAETNA