Provider Demographics
NPI:1295803047
Name:FREDERICK, TIM E (MD)
Entity type:Individual
Prefix:DR
First Name:TIM
Middle Name:E
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 2580
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65801-2580
Mailing Address - Country:US
Mailing Address - Phone:417-829-4620
Mailing Address - Fax:417-829-4316
Practice Address - Street 1:1965 S FREMONT AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65804-2201
Practice Address - Country:US
Practice Address - Phone:417-820-9123
Practice Address - Fax:417-820-3935
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2011-02-11
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MO20040041602084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208757807Medicaid
P00141755OtherRAILROAD MEDICARE
431560263024OtherTRICARE
MOB61956Medicare UPIN
MO208757807Medicaid