Provider Demographics
NPI:1477558492
Name:FREDRICKSON, BRUCE E (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:E
Last Name:FREDRICKSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 HARRISON ST
Mailing Address - Street 2:STE 130
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-3064
Mailing Address - Country:US
Mailing Address - Phone:315-464-4472
Mailing Address - Fax:315-464-5223
Practice Address - Street 1:550 HARRISON ST
Practice Address - Street 2:STE 130
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202-3064
Practice Address - Country:US
Practice Address - Phone:315-464-4472
Practice Address - Fax:315-464-5223
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2007-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY122366207XS0117X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the Spine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00522514Medicaid
NY122366OtherLICENSE
NYB81731Medicare UPIN