Provider Demographics
NPI:1720065931
Name:FREDERICK, HAL M (MD)
Entity type:Individual
Prefix:
First Name:HAL
Middle Name:M
Last Name:FREDERICK
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:PO BOX 100041
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30156-9241
Mailing Address - Country:US
Mailing Address - Phone:770-779-2178
Mailing Address - Fax:
Practice Address - Street 1:2428 SANTA MONICA BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90404-2045
Practice Address - Country:US
Practice Address - Phone:310-315-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0317412085R0202X
CAG521822085B0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000393698Medicaid
GA30BDKVDMedicare PIN
CACC774ZMedicare PIN
GAA89940Medicare UPIN
GA30BDKTSMedicare PIN