Provider Demographics
NPI:1508882010
Name:FREDERICH, JEFFREY L (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:L
Last Name:FREDERICH
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 1:120 PERSHING WAY
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42001-8914
Mailing Address - Country:US
Mailing Address - Phone:270-816-7526
Mailing Address - Fax:270-908-8322
Practice Address - Street 1:120 PERSHING WAY
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-8914
Practice Address - Country:US
Practice Address - Phone:270-816-7526
Practice Address - Fax:270-908-8322
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY43994207QA0401X, 208D00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100109070Medicaid
KY43994OtherKENTUCKY MEDICAL LICENSE
KY43994OtherKENTUCKY MEDICAL LICENSE