Healthcare Provider Details

I. General information

NPI: 1043483712
Provider Name (Legal Business Name): FREDERICKA C TATE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2008
Last Update Date: 08/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1018 NORTH BETHLEHEM PIKE SUITE 200B
SPRINGHOUSE PA
19477
US

IV. Provider business mailing address

6113 WEST MILL RD
FLOURTOWN PA
19031
US

V. Phone/Fax

Practice location:
  • Phone: 215-643-9151
  • Fax: 215-836-1087
Mailing address:
  • Phone: 215-643-9151
  • Fax: 215-836-1087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD011929E
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierB004643700
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerBCBS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: