Provider Demographics
NPI:1124211172
Name:FREMONT FAMILY MEDICINE, INC.
Entity Type:Organization
Organization Name:FREMONT FAMILY MEDICINE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR, MEDICAL STAFF SERVICES
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:K
Authorized Official - Last Name:WOOLLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CPMSP, CPCS
Authorized Official - Phone:419-334-6624
Mailing Address - Street 1:1916 GLEN SPRINGS DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:OH
Mailing Address - Zip Code:43420-3293
Mailing Address - Country:US
Mailing Address - Phone:419-332-4223
Mailing Address - Fax:419-332-9099
Practice Address - Street 1:1916 GLEN SPRINGS DR
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:OH
Practice Address - Zip Code:43420-3293
Practice Address - Country:US
Practice Address - Phone:419-332-4223
Practice Address - Fax:419-332-9099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-23
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-084980207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1715142OtherCORPORATION CERTIFICATE