Provider Demographics
NPI:1437356532
Name:J BRIAN FREDERICK, M.D., PLLC
Entity Type:Organization
Organization Name:J BRIAN FREDERICK, M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:BRIAN
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:606-325-6888
Mailing Address - Street 1:617 23RD ST STE 415
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101
Mailing Address - Country:US
Mailing Address - Phone:606-325-6888
Mailing Address - Fax:606-326-9368
Practice Address - Street 1:617 23RD ST STE 415
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2845
Practice Address - Country:US
Practice Address - Phone:606-325-6888
Practice Address - Fax:606-326-9368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-02
Last Update Date:2013-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39332174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64103179Medicaid
KY64103179Medicaid
KY0974601Medicare ID - Type Unspecified