Provider Demographics
NPI:1528009065
Name:FREDRICKSON, LAUREN (MD)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:FREDRICKSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1995 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OH
Mailing Address - Zip Code:44460-2423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1995 E STATE ST
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OH
Practice Address - Zip Code:44460-2423
Practice Address - Country:US
Practice Address - Phone:330-332-1551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-08
Last Update Date:2014-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35062338146D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH942460636205OtherCARESOURCE
OHP00194286OtherMEDICARE RR-GA
OHP00194286OtherMEDICARE RR-GA
OHFR4150751Medicare ID - Type Unspecified
OH0850879Medicare ID - Type Unspecified