Healthcare Provider Details

I. General information

NPI: 1104262617
Provider Name (Legal Business Name): CHAD FREDERICKSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/13/2013
Last Update Date: 05/01/2025
Certification Date: 05/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

INFIRMARY RD
BATON ROUGE LA
70803-2401
US

IV. Provider business mailing address

INFIRMARY RD
BATON ROUGE LA
70803-2401
US

V. Phone/Fax

Practice location:
  • Phone: 225-578-5633
  • Fax: 225-578-5655
Mailing address:
  • Phone: 225-578-5633
  • Fax: 225-578-5655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATH.200132
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License NumberATH.200132
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: