Provider Demographics
NPI:1811996796
Name:FREDERIKSEN, MARILYNN E (MD)
Entity type:Individual
Prefix:
First Name:MARILYNN
Middle Name:E
Last Name:FREDERIKSEN
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 1:945 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53233-1305
Mailing Address - Country:US
Mailing Address - Phone:414-219-7956
Mailing Address - Fax:
Practice Address - Street 1:945 N 12TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53233-1305
Practice Address - Country:US
Practice Address - Phone:414-219-7956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36058725207VM0101X, 207VM0101X
WI68138207VM0101X
NM336.023314207VM0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VM0101XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyMaternal & Fetal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL1627904OtherBLUE CROSS/BLUE SHIELD NO
WI100071887Medicaid
D14599Medicare UPIN