Provider Demographics
NPI:1609348879
Name:KYEM, FRED
Entity Type:Individual
Prefix:MR
First Name:FRED
Middle Name:
Last Name:KYEM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6908 ANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-1312
Mailing Address - Country:US
Mailing Address - Phone:215-248-0495
Mailing Address - Fax:215-247-0549
Practice Address - Street 1:6908 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119-1312
Practice Address - Country:US
Practice Address - Phone:215-248-0495
Practice Address - Fax:215-247-0549
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-27
Last Update Date:2018-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA27143601374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103027305002Medicaid