Healthcare Provider Details

I. General information

NPI: 1720065931
Provider Name (Legal Business Name): HAL M FREDERICK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 08/11/2022
Certification Date: 08/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2428 SANTA MONICA BLVD
SANTA MONICA CA
90404-2045
US

IV. Provider business mailing address

PO BOX 100041
KENNESAW GA
30156-9241
US

V. Phone/Fax

Practice location:
  • Phone: 310-315-1000
  • Fax:
Mailing address:
  • Phone: 770-779-2178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number031741
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberG52182
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: