Provider Demographics
NPI:1104262617
Name:FREDERICKSON, CHAD
Entity type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:FREDERICKSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:INFIRMARY RD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70803-2401
Mailing Address - Country:US
Mailing Address - Phone:225-578-5633
Mailing Address - Fax:225-578-5655
Practice Address - Street 1:INFIRMARY RD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70803-2401
Practice Address - Country:US
Practice Address - Phone:225-578-5633
Practice Address - Fax:225-578-5655
Is Sole Proprietor?:No
Enumeration Date:2013-05-13
Last Update Date:2025-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAATH.2001322255A2300X, 2081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer