Provider Demographics
NPI:1932640992
Name:AVERY, FREDRICK M (CERTIFIED PROSTHETIS)
Entity Type:Individual
Prefix:
First Name:FREDRICK
Middle Name:M
Last Name:AVERY
Suffix:
Gender:M
Credentials:CERTIFIED PROSTHETIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 VILLA CREST DR
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-6016
Mailing Address - Country:US
Mailing Address - Phone:865-691-7967
Mailing Address - Fax:865-971-5445
Practice Address - Street 1:2900 SUTHERLAND AVE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-4536
Practice Address - Country:US
Practice Address - Phone:865-524-2285
Practice Address - Fax:865-971-5445
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-10
Last Update Date:2017-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNPRO0000000036335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0448620001Medicare UPIN