Healthcare Provider Details

I. General information

NPI: 1396976577
Provider Name (Legal Business Name): FREMONT EAR NOSE AND THROAT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2009
Last Update Date: 09/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8185 HIGHWAY 789
LANDER WY
82520-2942
US

IV. Provider business mailing address

8185 HIGHWAY 789
LANDER WY
82520-2942
US

V. Phone/Fax

Practice location:
  • Phone: 307-335-7555
  • Fax:
Mailing address:
  • Phone: 307-335-7555
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. WALTER DAVIS MERRITT
Title or Position: PRESIDENT
Credential: MD
Phone: 307-335-7555