Active NPI
Fall River Medical, PLLC
- Primary Care Clinic/Center
- Rexburg, ID
National Provider Identifier
1457698987
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Primary Care Clinic/Center
- License
- O-0518
- Legal business name
- FALL RIVER MEDICAL, PLLC
- Practice address
- 21 Winn Dr
Rexburg, ID 83440 - Phone
- (208) 881-5222
- Fax
- (877) 441-4715
- NPI assigned
- Jan 3, 2013
- Organization subpart
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Authorized official
- Name
- Dr. Austin C Gillette, MD
- Title
- Owner
- Phone
- (208) 881-5222
Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.
Specialties & licenses 5
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Clinic/Center | 261Q00000X | O-0518 | ID | |
| Primary Care Clinic/Center | 261QP2300X | O-0518 | ID | Primary |
| Research Clinic/Center | 261QR1100X | O-0518 | ID | |
| Urgent Care Clinic/Center | 261QU0200X | O-0518 | ID | |
| Durable Medical Equipment & Medical Supplies | 332B00000X |
Addresses
Primary practice location
21 Winn Dr
Rexburg, ID 83440
Mailing address
21 Winn Dr
Rexburg, ID 83440-5277
Phone (208) 220-1057
Other identifiers 2
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1083810287 | Other | ID | NPI |
| 1972709103 | Other | ID | NPI |
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Enrolled in ID
Enrollment records 1
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| O20130808000831 | ID | Part B Supplier - Clinic/Group Practice | 4981846698 |
Receives reassigned benefits from 11 practitioners Practice locations: Rexburg, ID |
Laboratory certificates & supplier records
Derived by NPIMapThese CMS records do not include an NPI. They are shown because their name and street address match this provider’s.
CLIA laboratory certificates
| CLIA number | Laboratory | Certificate | Expires |
|---|---|---|---|
| 13D2074775 | Fall River Family Medicine | Compliance | Mar 17, 2027 |
National Provider Directory
National Provider DirectoryLocations
2000 Trappers Loop
Rexburg, ID 83440
Phone (208) 881-5222
21 Winn Dr
Rexburg, ID 83440
Phone (208) 881-5222
Practitioners & affiliated clinicians
Practitioners 12
Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.
-
- Family Medicine Physician
- Rexburg, ID
- NPI 1972709103
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1357171200000",
"enumeration_type": "NPI-2",
"last_updated_epoch": "1574121600000",
"number": "1457698987",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "21 WINN DR",
"city": "REXBURG",
"state": "ID",
"postal_code": "834405277",
"telephone_number": "208-220-1057",
"fax_number": "188-851-2685"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "21 WINN DR",
"city": "REXBURG",
"state": "ID",
"postal_code": "83440",
"telephone_number": "208-881-5222",
"fax_number": "877-441-4715"
}
],
"practiceLocations": [],
"basic": {
"organization_name": "FALL RIVER MEDICAL, PLLC",
"organizational_subpart": "NO",
"enumeration_date": "2013-01-03",
"last_updated": "2019-11-19",
"status": "A",
"authorized_official_last_name": "GILLETTE",
"authorized_official_first_name": "AUSTIN",
"authorized_official_middle_name": "C",
"authorized_official_title_or_position": "OWNER",
"authorized_official_telephone_number": "208-881-5222",
"authorized_official_name_prefix": "Dr.",
"authorized_official_credential": "MD"
},
"taxonomies": [
{
"code": "261Q00000X",
"taxonomy_group": "",
"desc": "Clinic/Center",
"state": "ID",
"license": "O-0518",
"primary": false
},
{
"code": "261QP2300X",
"taxonomy_group": "",
"desc": "Clinic/Center, Primary Care",
"state": "ID",
"license": "O-0518",
"primary": true
},
{
"code": "261QR1100X",
"taxonomy_group": "",
"desc": "Clinic/Center, Research",
"state": "ID",
"license": "O-0518",
"primary": false
},
{
"code": "261QU0200X",
"taxonomy_group": "",
"desc": "Clinic/Center, Urgent Care",
"state": "ID",
"license": "O-0518",
"primary": false
},
{
"code": "332B00000X",
"taxonomy_group": "",
"desc": "Durable Medical Equipment & Medical Supplies",
"state": null,
"license": null,
"primary": false
}
],
"identifiers": [
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NPI",
"identifier": "1083810287",
"state": "ID"
},
{
"code": "01",
"desc": "Other (non-Medicare)",
"issuer": "NPI",
"identifier": "1972709103",
"state": "ID"
}
],
"endpoints": [],
"other_names": []
}Other providers in Rexburg, ID
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 19, 2019; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
- Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.