Healthcare Provider Details

I. General information

NPI: 1811996796
Provider Name (Legal Business Name): MARILYNN E FREDERIKSEN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2005
Last Update Date: 09/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

945 N 12TH ST
MILWAUKEE WI
53233-1305
US

IV. Provider business mailing address

945 N 12TH ST
MILWAUKEE WI
53233-1305
US

V. Phone/Fax

Practice location:
  • Phone: 414-219-7956
  • Fax:
Mailing address:
  • Phone: 414-219-7956
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number36058725
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207VM0101X
TaxonomyMaternal & Fetal Medicine Physician
License Number68138
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: