MEDICARE: RAFI FREDMAN MD

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	2086S0122X	Plastic and Reconstructive Surgery Physician	2019032397	MO

General Provider Information

NPI Number	:	1972923126
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RAFI FREDMAN MD

Provider Business Mailing Address
First Line	:	1551 WALL ST STE 420
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63303-3541
Country	:	US
Telephone Number	:	636-329-4036
Fax Number	:

Provider Business Practice Location Address
First Line	:	1551 WALL ST STE 420
Second Line	:
City	:	SAINT CHARLES
State	:	MO
Zip	:	63303-3541
Country	:	US
Telephone Number	:	636-329-4036
Fax Number	:	636-206-2898

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

Provider Enumeration Date	:	04/25/2014
Last Update Date	:	12/17/2021

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