| Organization Name: | FREMONT FAMILY MEDICINE PC |
| NPI Number: | 1255704177 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | RONALD K ELLSWORTH (DOCTOR/OWNER) |
| Mailing Address: | 30 W Main St Saint Anthony |
| State: | ID US |
| Postal Code: | 834452113 |
| Phone Number: | 2086802716 |
| Fax Number: | |
| NPI Enumeration Date: | 11/02/2015 |
| NPI Last Update Date: | 11/02/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QP2300X |
| License Number: | M-11978 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ID |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Primary Care |
| Taxonomy Definition: | |