Healthcare Provider Details

I. General information

NPI: 1477558492
Provider Name (Legal Business Name): BRUCE E FREDRICKSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 10/05/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 HARRISON ST STE 130
SYRACUSE NY
13202-3064
US

IV. Provider business mailing address

550 HARRISON ST STE 130
SYRACUSE NY
13202-3064
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-4472
  • Fax: 315-464-5223
Mailing address:
  • Phone: 315-464-4472
  • Fax: 315-464-5223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207XS0117X
TaxonomyOrthopaedic Surgery of the Spine Physician
License Number122366
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number122366
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: