Provider Demographics
NPI:1255704177
Name:FREMONT FAMILY MEDICINE PC
Entity type:Organization
Organization Name:FREMONT FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:K
Authorized Official - Last Name:ELLSWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-680-2716
Mailing Address - Street 1:30 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ANTHONY
Mailing Address - State:ID
Mailing Address - Zip Code:83445-2113
Mailing Address - Country:US
Mailing Address - Phone:208-680-2716
Mailing Address - Fax:
Practice Address - Street 1:30 W MAIN ST
Practice Address - Street 2:
Practice Address - City:SAINT ANTHONY
Practice Address - State:ID
Practice Address - Zip Code:83445-2113
Practice Address - Country:US
Practice Address - Phone:208-680-2716
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-11-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM-11978261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care