Provider Demographics
NPI:1487656393
Name:FREDERICK, RANDALL C (MD)
Entity Type:Individual
Prefix:
First Name:RANDALL
Middle Name:C
Last Name:FREDERICK
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 1:8000 WOLF RIVER BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1727
Mailing Address - Country:US
Mailing Address - Phone:901-747-3630
Mailing Address - Fax:901-747-4039
Practice Address - Street 1:8000 WOLF RIVER BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1727
Practice Address - Country:US
Practice Address - Phone:901-747-3630
Practice Address - Fax:901-747-4039
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000013328207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNA97052Medicare UPIN