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General NPI Number Information
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NPI Number | 1255704177
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Entity Type | Organization
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Legal Business Name | FREMONT FAMILY MEDICINE PC
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Dates
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Enumeration Date | 11/02/2015
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Last Update Date | 11/02/2015
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Provider Practice Location Address
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Address Line | 30 W MAIN ST
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City | SAINT ANTHONY
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State | ID
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Zip | 83445-2113
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Country | US
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Telephone | 208-680-2716
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Fax |
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Provider Business Mailing Address
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Address Line | 30 W MAIN ST
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City | SAINT ANTHONY
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State | ID
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Zip | 83445-2113
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Country | US
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Telephone | 208-680-2716
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Fax |
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Authorized Official
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Title or Position | DOCTOR/OWNER
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Name | DR. RONALD K ELLSWORTH
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Credential | M.D.
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Telephone | 208-680-2716
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number | M-11978
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License Number State | ID
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