Provider Demographics
NPI:1669453213
Name:FREDERICK, JOHN RANDALL (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RANDALL
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1650 HUNTINGDON PIKE
Mailing Address - Street 2:SUITE 154
Mailing Address - City:MEADOWBROOK
Mailing Address - State:PA
Mailing Address - Zip Code:19046-8004
Mailing Address - Country:US
Mailing Address - Phone:215-938-3145
Mailing Address - Fax:215-938-3144
Practice Address - Street 1:1650 HUNTINGDON PIKE
Practice Address - Street 2:SUITE 154
Practice Address - City:MEADOWBROOK
Practice Address - State:PA
Practice Address - Zip Code:19046-8004
Practice Address - Country:US
Practice Address - Phone:215-938-3145
Practice Address - Fax:215-938-3144
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAM.D.032063E208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1886916-03Medicaid
PA053181QCWMedicare PIN
PA1886916-03Medicaid