MEDICARE: RUTH K. FREDERICKS, M.D.

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	2084N0400X	Neurology Physician	11722	MS

General Provider Information

NPI Number	:	1427007400
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RUTH K. FREDERICKS, M.D.

Provider Business Mailing Address
First Line	:	PO BOX 22670
Second Line	:
City	:	JACKSON
State	:	MS
Zip	:	39225-2670
Country	:	US
Telephone Number	:	601-939-0361
Fax Number	:	601-939-5210

Provider Business Practice Location Address
First Line	:	971 LAKELAND DR
Second Line	:	SUITE 557, WEST TOWER
City	:	JACKSON
State	:	MS
Zip	:	39216-4643
Country	:	US
Telephone Number	:	601-326-4602
Fax Number	:	601-326-4632

Authorized Official
Title or Position	:	OWNER
Name	:	DR. RUTH KELLUM FREDERICKS
Credential	:	M.D.
Telephone Number	:	601-939-0361

Provider Enumeration Date	:	05/08/2006
Last Update Date	:	03/15/2013

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