Provider Demographics
NPI:1588643118
Name:FRIEMOTH, JERRY ALAN (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:ALAN
Last Name:FRIEMOTH
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 ALBERT SABIN WAY
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45267-2827
Mailing Address - Country:US
Mailing Address - Phone:513-584-4457
Mailing Address - Fax:513-584-2222
Practice Address - Street 1:231 ALBERT SABIN WAY
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45267
Practice Address - Country:US
Practice Address - Phone:513-584-4457
Practice Address - Fax:513-584-2222
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2018-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.037521207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0529208Medicaid
OHFR7362851Medicare PIN
OHFR4123372Medicare PIN
OHFR4123373Medicare PIN
OH4123377Medicare PIN
OH0529208Medicaid
OH0529208Medicaid