Basic Information
| Provider Information | |||||||||
| NPI: | 1053508564 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FREMONT ANESTHESIA ASSOCIATE, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 30918 | ||||||||
| Address2: | |||||||||
| City: | BILLINGS | ||||||||
| State: | MT | ||||||||
| PostalCode: | 591160918 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3175672180 | ||||||||
| FaxNumber: | 3175672191 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 W SUNSET DR | ||||||||
| Address2: | |||||||||
| City: | RIVERTON | ||||||||
| State: | WY | ||||||||
| PostalCode: | 825012274 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8009671646 | ||||||||
| FaxNumber: | 3175672191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/28/2007 | ||||||||
| LastUpdateDate: | 11/25/2009 | ||||||||
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| AuthorizedOfficialLastName: | MULLINIX | ||||||||
| AuthorizedOfficialFirstName: | MATTHEW | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING GROUP MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 3078564161 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CRNA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | WY | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Anesthesiology | 367500000X | WY | Y | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | DG4268 | 01 | WY | RAILROAD MEDICARE | OTHER | 1053508564 | 05 | WY | MEDICAID | 06208001 | 01 | WY | BCBS | OTHER |