Provider Demographics
NPI:1528039930
Name:FREDERICKSON, RENEE A (MD)
Entity Type:Individual
Prefix:DR
First Name:RENEE
Middle Name:A
Last Name:FREDERICKSON
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 1:905 HIGHLAND BLVD 4440
Mailing Address - Street 2:BOZEMAN HEALTH WOMEN'S SPECIALISTS
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6901
Mailing Address - Country:US
Mailing Address - Phone:406-414-5150
Mailing Address - Fax:
Practice Address - Street 1:905 HIGHLAND BLVD
Practice Address - Street 2:SUITE 4500
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6903
Practice Address - Country:US
Practice Address - Phone:406-414-5150
Practice Address - Fax:406-414-5175
Is Sole Proprietor?:No
Enumeration Date:2006-02-01
Last Update Date:2021-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT69114207V00000X
OH35-086689207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1528039930Medicaid
OHFR4169241Medicare ID - Type Unspecified