MEDICARE: DR. RONALD JAMES FREDERICK JR. PHD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	LP4015	MN

General Provider Information

NPI Number	:	1417957101
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RONALD JAMES FREDERICK JR. PHD

Provider Business Mailing Address
First Line	:	3100 W LAKE ST
Second Line	:	SUITE 107
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55416-4527
Country	:	US
Telephone Number	:	612-926-8149
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 W LAKE ST
Second Line	:	SUITE 107
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55416-4527
Country	:	US
Telephone Number	:	612-926-8149
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2005
Last Update Date	:	07/08/2007

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