Provider Demographics
NPI:1639221203
Name:FREDERICK, PHILIP (MD)
Entity Type:Individual
Prefix:
First Name:PHILIP
Middle Name:
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 1:75 CLEARWATER DR
Mailing Address - Street 2:SUITE 106
Mailing Address - City:FALMOUTH
Mailing Address - State:ME
Mailing Address - Zip Code:04105-1339
Mailing Address - Country:US
Mailing Address - Phone:207-400-8570
Mailing Address - Fax:207-400-8580
Practice Address - Street 1:75 CLEARWATER DR
Practice Address - Street 2:SUITE 106
Practice Address - City:FALMOUTH
Practice Address - State:ME
Practice Address - Zip Code:04105-1339
Practice Address - Country:US
Practice Address - Phone:207-400-8570
Practice Address - Fax:207-400-8580
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2009-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME012049207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME301260099Medicaid
C66229OtherHARVARD PILGRIM HEALTHCAR
ME046861OtherANTHEM
3391930OtherAETNA
ME402700099Medicaid
C66229OtherHARVARD PILGRIM HEALTHCAR
ME402700099Medicaid
MX7911Medicare PIN
ME301260099Medicaid