NPIMap

Organization Active NPI

Fall River Medical, PLLC

  • Primary Care Clinic/Center
  • Rexburg, ID
National Provider Identifier
1457698987
Registry record updated Nov 19, 2019
On this page

Key facts

NPPES NPI Registry
Primary specialty
Primary Care Clinic/CenterTaxonomy code 261QP2300X
License
O-0518 Issued in ID
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
Last updated
Nov 19, 2019By the provider in NPPES
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 19, 2019

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Dr. Austin C Gillette, MDNPI 1083810287
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)CodeLicenseStatePrimary
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

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ID

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
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 NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
13D2074775Fall River Family Medicine21 Winn Dr, Rexburg, ID 83440ComplianceMar 17, 2027

National Provider Directory

National Provider Directory

Locations

2000 Trappers Loop
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, and the practitioner matching its NPPES authorized official.

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": [],
    "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.

Verify at the official NPI Registry.