Provider Demographics
NPI:1851524540
Name:FRED W LAFFERTY MD, INC
Entity Type:Organization
Organization Name:FRED W LAFFERTY MD, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FREDERIC
Authorized Official - Middle Name:W
Authorized Official - Last Name:LAFFERTY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-381-1142
Mailing Address - Street 1:1611 S GREEN RD
Mailing Address - Street 2:SUITE 147
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-4128
Mailing Address - Country:US
Mailing Address - Phone:216-381-1142
Mailing Address - Fax:216-381-6459
Practice Address - Street 1:1611 S GREEN RD
Practice Address - Street 2:SUITE 147
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-4128
Practice Address - Country:US
Practice Address - Phone:216-381-1142
Practice Address - Fax:216-381-6459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-27
Last Update Date:2009-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH23458207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0090584Medicaid
LA0118772Medicare PIN
C00487Medicare UPIN