Healthcare Provider Details

I. General information

NPI: 1962445171
Provider Name (Legal Business Name): JOHN E FREDELL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2006
Last Update Date: 02/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40520 COUNTY HIGHWAY 34
OGEMA MN
56569-9612
US

IV. Provider business mailing address

705 PLEASANT AVE S
PARK RAPIDS MN
56470-1440
US

V. Phone/Fax

Practice location:
  • Phone: 218-983-4300
  • Fax: 218-983-6394
Mailing address:
  • Phone: 218-732-2800
  • Fax: 218-732-2857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number24059
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: