Provider Demographics
NPI:1508279910
Name:FRYDRYCH, LYNN MARIE (MD)
Entity type:Individual
Prefix:
First Name:LYNN
Middle Name:MARIE
Last Name:FRYDRYCH
Suffix:
Gender:F
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:PO BOX 505673
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63150-5673
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3555 S NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65807-7310
Practice Address - Country:US
Practice Address - Phone:417-875-3246
Practice Address - Fax:417-875-3810
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-04
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD480968208200000X
CA162004390200000X
MI4301104772390200000X
MO2024011403208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program