Russell J Fredrickson, MD

Primary specialty

Family Medicine PhysicianTaxonomy code 207Q00000X

License

44683 Issued in WI

Practice address

723 Park Ridge LN
North Fond Du Lac, WI 54937-1385

Phone

(920) 926-8600

NPI assigned

Nov 3, 2005

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Electronic endpoints 2

Medicare fee-for-service enrollment

Enrolled in WI

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: Yes

Green means eligible to order or refer.

Enrollment records 1

Specialty

Family Practice

Education

University of Wisconsin School of Medicine, 2001

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Telehealth

Offers telehealth services

Group practices

Agnesian Healthcare IncGroup PAC ID 1658289624, 392 clinicians

Practice addresses (Care Compare)

Hospital & facility affiliations

• SSM Health at Home Home Health - Fond Du Lac Home health agency, Fond Du Lac, WI, CCN 527113
• SSM Health at Home Hospice Hospice, Fond Du Lac, WI, CCN 521512
• SSM Health St Agnes Hospital-Fond Du Lac Hospital, Fond Du Lac, WI, CCN 520088
• Ripon Medical Center Hospital, Ripon, WI, CCN 521321

Procedures performed for Medicare patients

Medicare enrollment (NPD)

Enrolled

Credentials

Doctor of Medicine

State licenses

Practice roles

Locations

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Agnesian Healthcare, Inc

  • General Acute Care Hospital
  • Fond Du Lac, WI
  • NPI 1346228541
  Medicare reassignment Care Compare group NPD
• Agnesian Healthcare Inc

  • Community/Retail Pharmacy
  • Waupun, WI
  • NPI 1366417917
  NPD

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

• Agnesian Healthcare, Inc

  • General Acute Care Hospital
  • Fond Du Lac, WI
  • NPI 1346228541
  Care Compare affiliation
• Agnesian Healthcare, Inc

  • Home Health Agency
  • Fond Du Lac, WI
  • NPI 1861467144
  Care Compare affiliation
• Agnesian Healthcare, Inc

  • Community Based Hospice Care Agency
  • Fond Du Lac, WI
  • NPI 1942274717
  Care Compare affiliation
• Ripon Medical Center Inc

  • Critical Access Hospital
  • Ripon, WI
  • NPI 1053362624
  Care Compare affiliation

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1130976000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1607558400000",
    "number": "1881685261",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "420 E DIVISION ST",
            "city": "FOND DU LAC",
            "state": "WI",
            "postal_code": "549354560",
            "telephone_number": "920-926-8340",
            "fax_number": "920-926-8370"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "723 PARK RIDGE LN",
            "city": "NORTH FOND DU LAC",
            "state": "WI",
            "postal_code": "549371385",
            "telephone_number": "920-926-8600"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FREDRICKSON",
        "first_name": "RUSSELL",
        "middle_name": "J",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2005-11-03",
        "last_updated": "2020-12-10",
        "certification_date": "2020-12-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "WI",
            "license": "44683",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "34301400",
            "state": "WI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "RAILROAD MEDICARE",
            "identifier": "P00140682",
            "state": "WI"
        }
    ],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "rfredrickson332088@direct-ehr-ssmhc.com",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "rfredrickson332088@direct-ehr-ssmhc.com",
            "address_1": "723 Park Ridge Ln",
            "city": "North Fond Du Lac",
            "state": "WI",
            "country_code": "US",
            "postal_code": "549371385",
            "country_name": "United States",
            "address_type": "DOM"
        },
        {
            "endpointType": "FHIR",
            "endpointTypeDescription": "FHIR URL",
            "endpoint": "https://fhir.ssmhc.com/fhir/api/FHIR/DSTU2/",
            "affiliation": "N",
            "use": "OTHER",
            "useDescription": "Other",
            "useOtherDescription": "FHIR API",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CCD",
            "address_1": "723 Park Ridge Ln",
            "city": "North Fond Du Lac",
            "state": "WI",
            "country_code": "US",
            "postal_code": "549371385",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Nicole R Dassow, NP
• Ceara Jenelle Dean, LPN
• Tiffany Gail Fisher, D.P.T
• Casey J Floros, D.D.S.
• Douglas R Fownes, MD
• Nicole Garcia
• Denise R Gatien Brux, NP
• Jamie Gueller
• Amy Sue Gumieny, NP
• Judith Ann Heilman

• Family Medicine Physician in North Fond Du Lac, WI
• Providers in North Fond Du Lac, WI by specialty
• Family Medicine Physician in Wisconsin

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 10, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.