Provider Demographics
NPI:1518921782
Name:FREDERICK, PAUL L (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:L
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 1:500 MEDICAL ARTS BLDG
Mailing Address - Street 2:SUITE 510
Mailing Address - City:KITTANNING
Mailing Address - State:PA
Mailing Address - Zip Code:16201-7137
Mailing Address - Country:US
Mailing Address - Phone:724-954-6115
Mailing Address - Fax:724-548-5683
Practice Address - Street 1:500 MEDICAL ARTS BLDG
Practice Address - Street 2:SUITE 510
Practice Address - City:KITTANNING
Practice Address - State:PA
Practice Address - Zip Code:16201-7137
Practice Address - Country:US
Practice Address - Phone:724-954-6115
Practice Address - Fax:724-548-5683
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD006827E208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0006359850003Medicaid
PA0006359850003Medicaid
PAC27568Medicare UPIN