Healthcare Provider Details

I. General information

NPI: 1891735551
Provider Name (Legal Business Name): FREDRIC NELSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 03/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5000 WOODLAND AVE
PHILA PA
19143-5137
US

IV. Provider business mailing address

432 N 6TH ST
PHILA PA
19123-4004
US

V. Phone/Fax

Practice location:
  • Phone: 215-726-9807
  • Fax:
Mailing address:
  • Phone: 215-925-2400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD021942
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: