Provider Demographics
NPI:1023288172
Name:FREMONT MEDICAL SERVICES PC
Entity type:Organization
Organization Name:FREMONT MEDICAL SERVICES PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:CHEYNE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-624-4402
Mailing Address - Street 1:430 N BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:ID
Mailing Address - Zip Code:83445-1425
Mailing Address - Country:US
Mailing Address - Phone:208-624-4402
Mailing Address - Fax:208-624-4409
Practice Address - Street 1:430 N BRIDGE ST
Practice Address - Street 2:
Practice Address - City:SAINT ANTHONY
Practice Address - State:ID
Practice Address - Zip Code:83445-1425
Practice Address - Country:US
Practice Address - Phone:208-624-4402
Practice Address - Fax:208-624-4409
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FREMONT MEDICAL SERVICES PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-05
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM4566261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
C47863Medicare UPIN