Provider Demographics
NPI:1316020357
Name:JEFFREY FREDERICK DPM PC
Entity Type:Organization
Organization Name:JEFFREY FREDERICK DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:248-545-0100
Mailing Address - Street 1:27901 WOODWARD AVE
Mailing Address - Street 2:SUITE 110
Mailing Address - City:BERKLEY
Mailing Address - State:MI
Mailing Address - Zip Code:48072-0919
Mailing Address - Country:US
Mailing Address - Phone:248-545-0100
Mailing Address - Fax:
Practice Address - Street 1:30005 FOREST DR
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:MI
Practice Address - Zip Code:48025-1580
Practice Address - Country:US
Practice Address - Phone:248-514-2604
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-23
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIJF001355213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4856354460OtherBLUE CROSS
MIDG9358OtherMEDICARE RAILROAD GROUP
MI1746737Medicaid
MI480005115OtherMEDICARE RAILROAD
MI480005115OtherMEDICARE RAILROAD
MIT34353Medicare UPIN
MI1746737Medicaid
MI0P39840001Medicare PIN