Provider Demographics
NPI:1336540814
Name:HILLIS, FREDRICK ALLEN (MD)
Entity Type:Individual
Prefix:
First Name:FREDRICK
Middle Name:ALLEN
Last Name:HILLIS
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 1:374 S SHORE DR
Mailing Address - Street 2:
Mailing Address - City:CULVER
Mailing Address - State:IN
Mailing Address - Zip Code:46511-8908
Mailing Address - Country:US
Mailing Address - Phone:574-842-3706
Mailing Address - Fax:574-842-3706
Practice Address - Street 1:374 S SHORE DR
Practice Address - Street 2:
Practice Address - City:CULVER
Practice Address - State:IN
Practice Address - Zip Code:46511-8908
Practice Address - Country:US
Practice Address - Phone:574-842-3706
Practice Address - Fax:574-842-3706
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-15
Last Update Date:2014-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02344A208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery