Provider Demographics
NPI:1871537704
Name:FRIEDEBACH, KATHERINE (MD)
Entity type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:
Last Name:FRIEDEBACH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3349 AMERICAN AVE STE C
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-1080
Mailing Address - Country:US
Mailing Address - Phone:573-632-0243
Mailing Address - Fax:573-632-6900
Practice Address - Street 1:3400 W TRUMAN BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-5712
Practice Address - Country:US
Practice Address - Phone:573-632-2777
Practice Address - Fax:573-632-2769
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001014722207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208388801Medicaid
MOH85120Medicare UPIN
MO208388801Medicaid