Provider Demographics
NPI:1699703017
Name:HOUSE, FREDRICK C (MD PC)
Entity type:Individual
Prefix:DR
First Name:FREDRICK
Middle Name:C
Last Name:HOUSE
Suffix:
Gender:M
Credentials:MD PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3646 WHEELER RD
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-6519
Mailing Address - Country:US
Mailing Address - Phone:706-863-0410
Mailing Address - Fax:706-863-9368
Practice Address - Street 1:3646 WHEELER RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30909-6519
Practice Address - Country:US
Practice Address - Phone:706-863-0410
Practice Address - Fax:706-863-9368
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12490174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000159541AMedicaid
GAD40183Medicare UPIN