Provider Demographics
NPI:1104883867
Name:FREDRICK, N BENJAMIN (MD)
Entity type:Individual
Prefix:
First Name:N
Middle Name:BENJAMIN
Last Name:FREDRICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:BENJAMIN
Other - Middle Name:
Other - Last Name:FREDRICK
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 858
Mailing Address - Street 2:MC A410
Mailing Address - City:HERSHEY
Mailing Address - State:PA
Mailing Address - Zip Code:17033-0858
Mailing Address - Country:US
Mailing Address - Phone:800-243-1455
Mailing Address - Fax:
Practice Address - Street 1:845 FISHBURN RD
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:PA
Practice Address - Zip Code:17033-2015
Practice Address - Country:US
Practice Address - Phone:717-531-8181
Practice Address - Fax:717-531-3509
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2019-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD420496207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019663470001Medicaid
H87726Medicare UPIN
PA0019663470001Medicaid