Provider Demographics
NPI:1326171026
Name:FREDERICKS, ROSE E (MD)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:E
Last Name:FREDERICKS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 JOYCE ANNE DR
Mailing Address - Street 2:
Mailing Address - City:MANVILLE
Mailing Address - State:RI
Mailing Address - Zip Code:02838-1017
Mailing Address - Country:US
Mailing Address - Phone:401-766-3334
Mailing Address - Fax:
Practice Address - Street 1:15 JOYCE ANNE DR
Practice Address - Street 2:
Practice Address - City:MANVILLE
Practice Address - State:RI
Practice Address - Zip Code:02838-1017
Practice Address - Country:US
Practice Address - Phone:401-766-3334
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA76629207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
B10071401OtherCIGNA
AA47729OtherHPHC
413130OtherBLUE CHIP
28351OtherBMC HEALTHNET
MA3099750Medicaid
MAJ13174OtherBCBSMA
076629OtherTUFTS
RI31041-9OtherBCBSRI
MA3099750Medicaid
28351OtherBMC HEALTHNET