MEDICARE: HAL M FREDERICK MD

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	2085R0202X	Diagnostic Radiology Physician	031741	GA
2	2085B0100X	Body Imaging Physician	G52182	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1720065931
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HAL M FREDERICK MD

Provider Business Mailing Address
First Line	:	PO BOX 100041
Second Line	:
City	:	KENNESAW
State	:	GA
Zip	:	30156-9241
Country	:	US
Telephone Number	:	770-779-2178
Fax Number	:

Provider Business Practice Location Address
First Line	:	2428 SANTA MONICA BLVD
Second Line	:
City	:	SANTA MONICA
State	:	CA
Zip	:	90404-2045
Country	:	US
Telephone Number	:	310-315-1000
Fax Number	:

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

Provider Enumeration Date	:	12/29/2005
Last Update Date	:	08/11/2022

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Directions to “ HAL M FREDERICK MD” Practice Location

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