Provider Demographics
NPI:1457698987
Name:FALL RIVER MEDICAL, PLLC
Entity Type:Organization
Organization Name:FALL RIVER MEDICAL, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:AUSTIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:GILLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:208-881-5222
Mailing Address - Street 1:21 WINN DR
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-5277
Mailing Address - Country:US
Mailing Address - Phone:208-220-1057
Mailing Address - Fax:188-851-2685
Practice Address - Street 1:21 WINN DR
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440
Practice Address - Country:US
Practice Address - Phone:208-881-5222
Practice Address - Fax:877-441-4715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-03
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDO-0518261Q00000X, 261QP2300X, 261QR1100X, 261QU0200X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QR1100XAmbulatory Health Care FacilitiesClinic/CenterResearch
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1083810287OtherNPI
ID1972709103OtherNPI
ID1972709103OtherNPI
ID1302907Medicare Oscar/Certification