Healthcare Provider Details

I. General information

NPI: 1336183045
Provider Name (Legal Business Name): RICHARD W. FRIEDEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 09/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1234 NAPIER AVE
ST JOSEPH MI
49120-2112
US

IV. Provider business mailing address

P.O. BOX 458
NILES MI
49120-0458
US

V. Phone/Fax

Practice location:
  • Phone: 269-983-8300
  • Fax:
Mailing address:
  • Phone: 269-684-0259
  • Fax: 269-684-0189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License Number4301091784
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: