Provider Demographics
NPI:1154411247
Name:FREDERICK, RANDY SCOTT (DC)
Entity type:Individual
Prefix:DR
First Name:RANDY
Middle Name:SCOTT
Last Name:FREDERICK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4607 LOCUST LN
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-4449
Mailing Address - Country:US
Mailing Address - Phone:717-545-6063
Mailing Address - Fax:717-545-8510
Practice Address - Street 1:4607 LOCUST LN
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-4449
Practice Address - Country:US
Practice Address - Phone:717-545-6063
Practice Address - Fax:717-545-8510
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC005233R111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA478570Medicare ID - Type Unspecified
PAU27859Medicare UPIN