Provider Demographics
NPI:1215933114
Name:FREDRICK, ROBERT S (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:S
Last Name:FREDRICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2051 W CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43606-3948
Mailing Address - Country:US
Mailing Address - Phone:419-291-2051
Mailing Address - Fax:419-479-6952
Practice Address - Street 1:2051 W CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43606-3948
Practice Address - Country:US
Practice Address - Phone:419-291-2051
Practice Address - Fax:419-479-6952
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35055622207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000031391OtherANTHEM-WWK
OH0690435Medicaid
MI344428256OtherPHCS
OH000000185513OtherANTHEM-CHS
OH9352225002OtherCIGNA
OH01514OtherPARAMOUNT
OH106250OtherCARE CHOICES
OH4243601OtherAETNA
OH30096OtherNATIONWIDE
MI3221935Medicaid
OH01-04057OtherUNITED
OH01397OtherPARAMOUNT
MI3424240Medicaid
MI6893OtherHPM
MI3221935Medicaid
OH9352225002OtherCIGNA
MI6893OtherHPM