Provider Demographics
NPI:1891795472
Name:HEIDENREICH, FRED
Entity Type:Individual
Prefix:
First Name:FRED
Middle Name:
Last Name:HEIDENREICH
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 1:1624 PACIFIC AVE
Mailing Address - Street 2:STE A
Mailing Address - City:NATRONA HEIGHTS
Mailing Address - State:PA
Mailing Address - Zip Code:15065-2145
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1624 PACIFIC AVE
Practice Address - Street 2:STE A
Practice Address - City:NATRONA HEIGHTS
Practice Address - State:PA
Practice Address - Zip Code:15065-2145
Practice Address - Country:US
Practice Address - Phone:724-226-1199
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-26
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD067719L207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01733040Medicaid
023965E21Medicare ID - Type Unspecified
PA01733040Medicaid