=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629538095
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN PAUL FREMAUX DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2019
-----------------------------------------------------
Last Update Date | 11/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 230 E MARYDALE AVE
-----------------------------------------------------
City | SOLDOTNA
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99669-7648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-262-3119
-----------------------------------------------------
Fax | 907-262-9290
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 230 E MARYDALE AVE
-----------------------------------------------------
City | SOLDOTNA
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99669-7648
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-262-3119
-----------------------------------------------------
Fax | 907-262-9290
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 125074291
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 196997
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------