Healthcare Provider Details

I. General information

NPI: 1568107050
Provider Name (Legal Business Name): FREDERICK MORGAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2022
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2621
US

IV. Provider business mailing address

PO BOX 860912 PROVIDER ENROLLMENT RST
MINNEAPOLIS MN
55486-0912
US

V. Phone/Fax

Practice location:
  • Phone: 617-726-5820
  • Fax:
Mailing address:
  • Phone: 507-284-2511
  • Fax: 507-284-0702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number82369
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: