Provider Demographics
NPI:1346449014
Name:FREDRICK, REBECCA A (DO)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:FREDRICK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26908 DETROIT RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-2398
Mailing Address - Country:US
Mailing Address - Phone:440-617-1823
Mailing Address - Fax:440-617-0884
Practice Address - Street 1:19800 DETROIT RD
Practice Address - Street 2:
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-1816
Practice Address - Country:US
Practice Address - Phone:440-333-1107
Practice Address - Fax:440-333-1064
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2020-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-009134207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2887961Medicaid
OHH322140Medicare PIN
OH4244262Medicare PIN