Provider Demographics
NPI:1962445171
Name:FREDELL, JOHN E (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:FREDELL
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 1:705 PLEASANT AVE S
Mailing Address - Street 2:
Mailing Address - City:PARK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56470-1440
Mailing Address - Country:US
Mailing Address - Phone:218-732-2800
Mailing Address - Fax:218-732-2857
Practice Address - Street 1:40520 COUNTY HIGHWAY 34
Practice Address - Street 2:
Practice Address - City:OGEMA
Practice Address - State:MN
Practice Address - Zip Code:56569-9612
Practice Address - Country:US
Practice Address - Phone:218-983-4300
Practice Address - Fax:218-983-6394
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2012-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN24059207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0106863OtherMEDICA #
MN10065OtherNDBS #
MN18686Medicaid
MNHP19497OtherHEALTHPARTNERS #
MN01603FROtherMNBS #
MN0106061OtherMEDICA #
MNDA9041015692OtherPREFERRED ONE #
MNMN100038OtherLHS/BANNERHEALTH #
MN0106058OtherMEDICA #
MN125910OtherUCARE #
MN900856OtherAMERICA'S PPO/ARAZ #
MNMN100038OtherLHS/BANNERHEALTH #
MN125910OtherUCARE #
MN089005885Medicare ID - Type UnspecifiedMN MEDICARE #
MN080043620Medicare ID - Type UnspecifiedRR MEDICARE #
MN18686Medicaid