Provider Demographics
NPI:1215715669
Name:GEM STATE ENT, PLLC
Entity type:Organization
Organization Name:GEM STATE ENT, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL CODER
Authorized Official - Prefix:
Authorized Official - First Name:BROOKE
Authorized Official - Middle Name:
Authorized Official - Last Name:FREIDENBERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-858-6008
Mailing Address - Street 1:2114 VILLAGE PARK AVE # 200
Mailing Address - Street 2:
Mailing Address - City:TWIN FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83301-4172
Mailing Address - Country:US
Mailing Address - Phone:208-804-1717
Mailing Address - Fax:208-804-1707
Practice Address - Street 1:2102 CANYON PLAZA DR
Practice Address - Street 2:
Practice Address - City:TWIN FALLS
Practice Address - State:ID
Practice Address - Zip Code:83301-4513
Practice Address - Country:US
Practice Address - Phone:208-352-7555
Practice Address - Fax:208-352-7333
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-18
Last Update Date:2025-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty