Provider Demographics
NPI:1922757129
Name:MYERS, FREDERICK R (NONE)
Entity Type:Individual
Prefix:MR
First Name:FREDERICK
Middle Name:R
Last Name:MYERS
Suffix:
Gender:M
Credentials:NONE
Other - Prefix:MR
Other - First Name:FRED
Other - Middle Name:R
Other - Last Name:MYERS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:NONE
Mailing Address - Street 1:59 BRADT HILL RD
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12134-5310
Mailing Address - Country:US
Mailing Address - Phone:518-921-0976
Mailing Address - Fax:
Practice Address - Street 1:59 BRADT HILL RD
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:NY
Practice Address - Zip Code:12134-5310
Practice Address - Country:US
Practice Address - Phone:518-921-0976
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-23
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY334986825207PE0004X
NY607400911207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services