MEDICARE: GEM STATE ENT, PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician

General Provider Information

NPI Number	:	1215715669
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GEM STATE ENT, PLLC

Provider Business Mailing Address
First Line	:	2114 VILLAGE PARK AVE # 200
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-4172
Country	:	US
Telephone Number	:	208-804-1717
Fax Number	:	208-804-1707

Provider Business Practice Location Address
First Line	:	2102 CANYON PLAZA DR
Second Line	:
City	:	TWIN FALLS
State	:	ID
Zip	:	83301-4513
Country	:	US
Telephone Number	:	208-352-7555
Fax Number	:	208-352-7333

Authorized Official
Title or Position	:	MEDICAL CODER
Name	:	BROOKE FREIDENBERGER
Credential	:
Telephone Number	:	208-858-6008

Provider Enumeration Date	:	09/18/2023
Last Update Date	:	04/08/2025

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