Healthcare Provider Details

I. General information

NPI: 1194829812
Provider Name (Legal Business Name): FREDERICK MEDICAL CLINIC PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2006
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 LIBERTY RD
WEST LIBERTY KY
41472-2049
US

IV. Provider business mailing address

PO BOX 607
WEST LIBERTY KY
41472-0607
US

V. Phone/Fax

Practice location:
  • Phone: 606-743-3114
  • Fax: 606-743-1404
Mailing address:
  • Phone: 606-743-3114
  • Fax: 606-743-1404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number183940
License Number StateKY

VIII. Authorized Official

Name: MR. JAMES DENZIL FREDERICK
Title or Position: ADMINISTRATION MEDICAL DIRECTOR
Credential: MD
Phone: 606-743-3114