Provider Demographics
NPI:1386007177
Name:FREDELL, ERIC (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:FREDELL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3845 24TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55406-3005
Mailing Address - Country:US
Mailing Address - Phone:612-876-5674
Mailing Address - Fax:
Practice Address - Street 1:3200 MACCORKLE AVE SE STE B-16
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25304-1227
Practice Address - Country:US
Practice Address - Phone:304-388-5848
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WV29748207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program