Provider Demographics
NPI:1043263551
Name:FREMONT RIDEOUT MEDICAL GROUP INC
Entity Type:Organization
Organization Name:FREMONT RIDEOUT MEDICAL GROUP INC
Other - Org Name:NORTH VALLEY ANES MED GRP INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GROUP PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:SERAFIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-749-4300
Mailing Address - Street 1:PO BOX 7096
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95267-0096
Mailing Address - Country:US
Mailing Address - Phone:209-956-7725
Mailing Address - Fax:209-956-7733
Practice Address - Street 1:726 FOURTH STREET
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901
Practice Address - Country:US
Practice Address - Phone:530-749-4300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ048062OtherBLUE SHIELD OF CA
CAGR0092251Medicaid
CAZZZ22822ZMedicare PIN
CAGR0092251Medicaid
CAZZZ22823ZMedicare PIN
CAZZZ22821ZMedicare PIN