Provider Demographics
NPI:1396718177
Name:FREDERICK, ERIC DAVID (MS, ATC, LAT)
Entity type:Individual
Prefix:MR
First Name:ERIC
Middle Name:DAVID
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:MS, ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1571 MOCKINGBIRD DR
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-3281
Mailing Address - Country:US
Mailing Address - Phone:270-753-3253
Mailing Address - Fax:270-809-5526
Practice Address - Street 1:MURRAY STATE UNIVERSITY
Practice Address - Street 2:217 STEWART STADIUM
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-3351
Practice Address - Country:US
Practice Address - Phone:270-809-5580
Practice Address - Fax:270-809-5526
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYAT2122255A2300X
TXAT13082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer