MEDICARE: MS. MARY L FREIDEL CSTCFA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZS0410X	Surgical Technologist	40351

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	40351	OTHER		NATIONAL CERTIFICATION

General Provider Information

NPI Number	:	1205954120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. MARY L FREIDEL CSTCFA

Provider Business Mailing Address
First Line	:	3615 5TH ST
Second Line	:	SUITE 101
City	:	RAPID CITY
State	:	SD
Zip	:	57701-6014
Country	:	US
Telephone Number	:	605-343-7208
Fax Number	:	605-343-7132

Provider Business Practice Location Address
First Line	:	3615 5TH ST
Second Line	:	SUITE 101
City	:	RAPID CITY
State	:	SD
Zip	:	57701-6014
Country	:	US
Telephone Number	:	605-343-7208
Fax Number	:	605-343-7132

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2007
Last Update Date	:	07/08/2007

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