Provider Demographics
NPI:1386626893
Name:FREMONT, SUSAN L (MD)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:L
Last Name:FREMONT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 SMITH RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-2787
Mailing Address - Country:US
Mailing Address - Phone:513-533-1199
Mailing Address - Fax:513-533-6000
Practice Address - Street 1:10675A LOVELAND MADEIRA RD
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:OH
Practice Address - Zip Code:45140-8965
Practice Address - Country:US
Practice Address - Phone:513-774-8220
Practice Address - Fax:513-774-8229
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073721207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2128852Medicaid
080193639Medicare PIN
OHP00915551Medicare PIN
OH0850395Medicare PIN
OHG74940Medicare UPIN
OHFR0850396Medicare PIN