Provider Demographics
NPI:1528009396
Name:FREMONT MEDICAL GROUP, INC.
Entity Type:Organization
Organization Name:FREMONT MEDICAL GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIKANO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:510-793-3033
Mailing Address - Street 1:734 MOWRY AVE
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94536-4115
Mailing Address - Country:US
Mailing Address - Phone:510-793-3033
Mailing Address - Fax:510-793-4952
Practice Address - Street 1:734 MOWRY AVE
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94536-4115
Practice Address - Country:US
Practice Address - Phone:510-793-3033
Practice Address - Fax:510-793-4952
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG4628207R00000X
CAG6855207R00000X
CAA44320207RC0000X
CAG66303207RG0100X
CAA53697207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Multi-Specialty
Not Answered207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Multi-Specialty
Not Answered207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0077610Medicaid
CAZZZ46056ZOtherBLUE SHIELD
CAGR0077610Medicaid
CAZZZ46056ZOtherBLUE SHIELD