Provider Demographics
NPI:1346281250
Name:FISH, FREDERICK S (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:S
Last Name:FISH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:119 14TH ST NW STE 240
Mailing Address - Street 2:
Mailing Address - City:NEW BRIGHTON
Mailing Address - State:MN
Mailing Address - Zip Code:55112-0007
Mailing Address - Country:US
Mailing Address - Phone:763-571-4000
Mailing Address - Fax:763-502-2966
Practice Address - Street 1:500 OSBORNE RD NE STE 330
Practice Address - Street 2:
Practice Address - City:FRIDLEY
Practice Address - State:MN
Practice Address - Zip Code:55432-2769
Practice Address - Country:US
Practice Address - Phone:763-571-4000
Practice Address - Fax:763-502-2966
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN26385207ND0101X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN394783100Medicaid
MN394783100Medicaid