Provider Demographics
NPI:1801899299
Name:BAHNSON, FREDERIC FRIES III (MD)
Entity type:Individual
Prefix:DR
First Name:FREDERIC
Middle Name:FRIES
Last Name:BAHNSON
Suffix:III
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 1:188 MEDICAL PARK DRIVE
Mailing Address - Street 2:SUITE B
Mailing Address - City:BREVARD
Mailing Address - State:NC
Mailing Address - Zip Code:28712
Mailing Address - Country:US
Mailing Address - Phone:828-884-6702
Mailing Address - Fax:828-884-6925
Practice Address - Street 1:188 MEDICAL PARK DRIVE
Practice Address - Street 2:SUITE B
Practice Address - City:BREVARD
Practice Address - State:NC
Practice Address - Zip Code:28712
Practice Address - Country:US
Practice Address - Phone:828-884-6702
Practice Address - Fax:828-884-6925
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2007-07-09
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
NC18599174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8910409Medicaid
NC1007740OtherUNITED HEALTH CARE
NC10409OtherBLUE CROSS BLUE SHIELD
NC80389OtherMEDCOST
NC2265056Medicare ID - Type UnspecifiedREGULAR MEDICARE
NC80389OtherMEDCOST