Provider Demographics
NPI:1790881290
Name:FREDERICK, PAUL
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:FREDERICK
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 1:02957 73RD ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-9364
Mailing Address - Country:US
Mailing Address - Phone:269-637-9099
Mailing Address - Fax:269-637-9224
Practice Address - Street 1:02957 73RD ST
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-9364
Practice Address - Country:US
Practice Address - Phone:269-637-9099
Practice Address - Fax:269-637-9224
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2008-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIM15501011004261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4800853Medicaid
MIOHO1023OtherBLUE CROSS BLUE SHIELD
MIOHO1023OtherBLUE CROSS BLUE SHIELD