Provider Demographics
NPI:1730115627
Name:FREDERICH, MICHAEL EDWIN (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EDWIN
Last Name:FREDERICH
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 1:4371 E LOHMAN AVE
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8255
Mailing Address - Country:US
Mailing Address - Phone:575-532-8900
Mailing Address - Fax:575-532-8910
Practice Address - Street 1:4371 E LOHMAN AVE
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88011-8255
Practice Address - Country:US
Practice Address - Phone:575-532-8900
Practice Address - Fax:575-532-8910
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2020-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22879207Q00000X
CAG84864207Q00000X
NMMD2009-0731207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810009924Medicaid
WVFR6036341Medicare PIN