Basic Information
| Provider Information | |||||||||
| NPI: | 1689013161 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FREMONT EMERGENCY SERVICES MANDAVIA LTD | ||||||||
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| OtherOrganizationName: | FREMONT EMERGENCY SERVICES (HENNER AND SEARS) LTD | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 638972 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452638972 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9259241600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3001 SAINT ROSE PKWY | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890523839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7026165000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2013 | ||||||||
| LastUpdateDate: | 01/10/2020 | ||||||||
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| AuthorizedOfficialLastName: | HARDY | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
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| AuthorizedOfficialTitleorPosition: | DIRECTOR PROVIDER ENROLLMENT | ||||||||
| AuthorizedOfficialTelephone: | 9252516901 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1689013161 | 05 | NV | MEDICAID |