Healthcare Provider Details

I. General information

NPI: 1023288172
Provider Name (Legal Business Name): FREMONT MEDICAL SERVICES PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2008
Last Update Date: 11/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

430 N BRIDGE ST
SAINT ANTHONY ID
83445-1425
US

IV. Provider business mailing address

430 N BRIDGE ST
SAINT ANTHONY ID
83445-1425
US

V. Phone/Fax

Practice location:
  • Phone: 208-624-4402
  • Fax: 208-624-4409
Mailing address:
  • Phone: 208-624-4402
  • Fax: 208-624-4409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberM4566
License Number StateID

VIII. Authorized Official

Name: DR. STEPHEN JAMES CHEYNE
Title or Position: PRESIDENT
Credential: MD
Phone: 208-624-4402