Provider Demographics
NPI:1891735551
Name:NELSON, FREDRIC (MD)
Entity Type:Individual
Prefix:
First Name:FREDRIC
Middle Name:
Last Name:NELSON
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 1:432 N 6TH ST
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19123-4004
Mailing Address - Country:US
Mailing Address - Phone:215-925-2400
Mailing Address - Fax:
Practice Address - Street 1:5000 WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19143-5137
Practice Address - Country:US
Practice Address - Phone:215-726-9807
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD021942208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA006616900Medicaid
PA006616900Medicaid
PA093638Medicare ID - Type Unspecified