MEDICARE: DR. TIFFANY ANN FREDERICKSON

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	208600000X	Surgery Physician	R-8763	IA
2	208600000X	Surgery Physician	TD151001	ME
3	208600000X	Surgery Physician	9138	SD

General Provider Information

NPI Number	:	1265669956
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIFFANY ANN FREDERICKSON

Provider Business Mailing Address
First Line	:	8412 KITT PEAK RD
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-9512
Country	:	US
Telephone Number	:	515-201-8982
Fax Number	:

Provider Business Practice Location Address
First Line	:	8412 KITT PEAK RD
Second Line	:
City	:	RAPID CITY
State	:	SD
Zip	:	57702-9512
Country	:	US
Telephone Number	:	515-201-8982
Fax Number	:

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

Provider Enumeration Date	:	06/19/2009
Last Update Date	:	09/15/2015

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