Provider Demographics
NPI:1861446379
Name:ILGENFRITZ, FREDERICK M (MD)
Entity Type:Individual
Prefix:
First Name:FREDERICK
Middle Name:M
Last Name:ILGENFRITZ
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 1:1224 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:HAMILTON
Mailing Address - State:MT
Mailing Address - Zip Code:59840-2338
Mailing Address - Country:US
Mailing Address - Phone:406-375-4823
Mailing Address - Fax:406-375-4846
Practice Address - Street 1:1150 WESTWOOD DR
Practice Address - Street 2:SUITE C
Practice Address - City:HAMILTON
Practice Address - State:MT
Practice Address - Zip Code:59840-5318
Practice Address - Country:US
Practice Address - Phone:406-363-4574
Practice Address - Fax:406-363-4569
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT8776208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1861446379Medicaid
WA1861446379Medicaid
ID1861446379Medicaid
MT026384Medicaid
B48454Medicare UPIN
MT026384Medicaid