Provider Demographics
NPI:1801106257
Name:BRYAN D FREDRICK MD LLC
Entity type:Organization
Organization Name:BRYAN D FREDRICK MD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRYAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:FREDRICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-726-9457
Mailing Address - Street 1:PO BOX 609
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:FL
Mailing Address - Zip Code:34451-0609
Mailing Address - Country:US
Mailing Address - Phone:352-725-6945
Mailing Address - Fax:
Practice Address - Street 1:1409 S WATERVIEW DR
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:FL
Practice Address - Zip Code:34450-3585
Practice Address - Country:US
Practice Address - Phone:352-726-9457
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME31083207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Single Specialty