Provider Demographics
NPI:1134863772
Name:FREDERICK, BENEDICT JOHN IV
Entity type:Individual
Prefix:
First Name:BENEDICT
Middle Name:JOHN
Last Name:FREDERICK
Suffix:IV
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 1:222 E FRANK ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-3515
Mailing Address - Country:US
Mailing Address - Phone:410-615-8558
Mailing Address - Fax:
Practice Address - Street 1:19000 ST JOES PKWY STE 310
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1477
Practice Address - Country:US
Practice Address - Phone:734-743-4540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-20
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Single Specialty