Provider Demographics
NPI:1487622551
Name:FREIDEL, JACK F (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:F
Last Name:FREIDEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 635283
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-5283
Mailing Address - Country:US
Mailing Address - Phone:859-344-5555
Mailing Address - Fax:859-344-5552
Practice Address - Street 1:107 BRIDGEWAY ST
Practice Address - Street 2:SUITE 100
Practice Address - City:AURORA
Practice Address - State:IN
Practice Address - Zip Code:47001-1378
Practice Address - Country:US
Practice Address - Phone:812-496-8785
Practice Address - Fax:812-926-0431
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2022-08-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01039463A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200026340Medicaid
IN172580HMedicare PIN
080115734Medicare PIN
IN178340Medicare PIN
E24253Medicare UPIN