Provider Demographics
NPI:1568630614
Name:WILLIAM RONALD FREDERICK
Entity type:Organization
Organization Name:WILLIAM RONALD FREDERICK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:870-338-9882
Mailing Address - Street 1:126 HICKORY HILL DR
Mailing Address - Street 2:
Mailing Address - City:HELENA
Mailing Address - State:AR
Mailing Address - Zip Code:72342-2302
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:126 HICKORY HILL DR
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:AR
Practice Address - Zip Code:72342-2302
Practice Address - Country:US
Practice Address - Phone:870-338-3322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2008-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
0789870001Medicare NSC