Provider Demographics
NPI:1699860015
Name:FREDERICK, BRIAN SHANE (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:SHANE
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:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-7025
Practice Address - Fax:864-560-7388
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR0699207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP00879458OtherRAILROAD MEDICARE
NC5910691Medicaid
SC238157Medicaid
SCH951918510Medicare PIN
SCP00655015Medicare PIN
SCP00879458OtherRAILROAD MEDICARE
KYH95191Medicare ID - Type Unspecified
SCH951919068Medicare PIN