Healthcare Provider Details

I. General information

NPI: 1891510707
Provider Name (Legal Business Name): FREDERICK PEDIATRIC ASSOCIATES P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/18/2024
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6550 MERCANTILE DR E STE 106
FREDERICK MD
21703-7656
US

IV. Provider business mailing address

87 THOMAS JOHNSON DR STE 101
FREDERICK MD
21702-4427
US

V. Phone/Fax

Practice location:
  • Phone: 301-668-6347
  • Fax: 301-668-9780
Mailing address:
  • Phone: 301-694-0606
  • Fax: 877-276-4919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: MARY JARVIS
Title or Position: OFFICE MANAGER
Credential:
Phone: 301-694-0606