Healthcare Provider Details

I. General information

NPI: 1508882010
Provider Name (Legal Business Name): JEFFREY L FREDERICH M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2006
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 PERSHING WAY
PADUCAH KY
42001-8914
US

IV. Provider business mailing address

3805 STILL MEADOW LN
LEXINGTON KY
40509-2951
US

V. Phone/Fax

Practice location:
  • Phone: 270-816-7526
  • Fax: 270-908-8322
Mailing address:
  • Phone: 270-816-7526
  • Fax: 270-908-8322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number43994
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number43994
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number43994
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: