Provider Demographics
NPI:1326045972
Name:FREDERICK, MARY GENA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:GENA
Last Name:FREDERICK
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1025 MEDICAL CENTER DR
Mailing Address - Street 2:DELANEY RADIOLOGISTS GROUP, PLLC
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401
Mailing Address - Country:US
Mailing Address - Phone:910-763-1800
Mailing Address - Fax:910-763-6419
Practice Address - Street 1:1025 MEDICAL CENTER DR
Practice Address - Street 2:DELANEY RADIOLOGISTS GROUP, PLLC
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401
Practice Address - Country:US
Practice Address - Phone:910-762-3882
Practice Address - Fax:910-343-6019
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2023-03-07
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NC93004692085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7901897Medicaid
NC8901898Medicaid
BF4245115OtherDEA
2194565BMedicare ID - Type Unspecified
NC204307Medicare PIN
F30173Medicare UPIN
NC7901897Medicaid