Provider Demographics
NPI:1871525907
Name:FREDRICK, NATHAN P (DO)
Entity type:Individual
Prefix:DR
First Name:NATHAN
Middle Name:P
Last Name:FREDRICK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 829
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29528-0829
Mailing Address - Country:US
Mailing Address - Phone:843-347-8015
Mailing Address - Fax:843-347-8017
Practice Address - Street 1:300 SINGLETON RIDGE RD
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526-9142
Practice Address - Country:US
Practice Address - Phone:843-347-8015
Practice Address - Fax:843-347-8017
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2011-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC637207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
020051649OtherMEDICARE RAILROAD
IL0361220182Medicaid
SCT00391Medicaid
P00679662OtherRAILROAD MCARE
ILP00936457OtherRRMCARE THRU CESIISC (GES)
ILP00936457OtherRRMCARE THRU CESIISC (GES)
IL210426001Medicare PIN
SCT00391Medicaid
SCH381998822Medicare PIN