1396718177 NPI number — MR. ERIC DAVID FREDERICK MS, ATC, LAT

Table of content: MR. ERIC DAVID FREDERICK MS, ATC, LAT (NPI 1396718177)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396718177 NPI number — MR. ERIC DAVID FREDERICK MS, ATC, LAT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FREDERICK
Provider First Name:
ERIC
Provider Middle Name:
DAVID
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MS, ATC, LAT
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:
1396718177
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:
1571 MOCKINGBIRD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MURRAY
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42071-3281
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-753-3253
Provider Business Mailing Address Fax Number:
270-809-5526

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
MURRAY STATE UNIVERSITY
Provider Second Line Business Practice Location Address:
217 STEWART STADIUM
Provider Business Practice Location Address City Name:
MURRAY
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42071-3351
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-809-5580
Provider Business Practice Location Address Fax Number:
270-809-5526
Provider Enumeration Date:
02/10/2006

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: 2255A2300X , with the licence number:  AT212 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2255A2300X , with the licence number: AT1308 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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