1114007481 NPI number — DR. JEFFREY A FRIED M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114007481 NPI number — DR. JEFFREY A FRIED M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRIED
Provider First Name:
JEFFREY
Provider Middle Name:
A
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114007481
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5048
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MACON
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31208-5048
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-477-0966
Provider Business Mailing Address Fax Number:
478-475-0084

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6501 PEAKE RD
Provider Second Line Business Practice Location Address:
BLDG 400
Provider Business Practice Location Address City Name:
MACON
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31210-8042
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-477-0966
Provider Business Practice Location Address Fax Number:
478-475-0084
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207X00000X , with the licence number:  040383 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 207XX0005X , with the licence number: 040383 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 52448324 002 . This is a "BCBS PROVIDER #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".
  • Identifier: P00308700 . This is a "RAIL ROAD MEDICARE #" identifier , issued by the state of ( GA ) . This identifiers is of the category "OTHER".




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