1225303274 NPI number — MEGAN ELIZABETH FRERICKS HAS

Table of content: MEGAN ELIZABETH FRERICKS HAS (NPI 1225303274)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225303274 NPI number — MEGAN ELIZABETH FRERICKS HAS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FRERICKS
Provider First Name:
MEGAN
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
HAS
Provider Gender Code:
F

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:
1225303274
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
851 BROKEN SOUND PARKWAY NW
Provider Second Line Business Mailing Address:
SUITE 120
Provider Business Mailing Address City Name:
BOCA RATON
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33487-3638
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-367-1623
Provider Business Mailing Address Fax Number:
561-299-5438

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13350 REFLECTIONS PARKWAY
Provider Second Line Business Practice Location Address:
SUITE 4-402
Provider Business Practice Location Address City Name:
FORT MEYERS
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33907-6539
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
239-936-1110
Provider Business Practice Location Address Fax Number:
239-437-9589
Provider Enumeration Date:
03/08/2012

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: 237700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 237700000X , with the licence number: AS4855 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 100565700 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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