Provider Demographics
NPI:1003849597
Name:FATUMA MIDAMBA MD INC.
Entity Type:Organization
Organization Name:FATUMA MIDAMBA MD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FATUMA
Authorized Official - Middle Name:
Authorized Official - Last Name:MIDAMBA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:440-834-1833
Mailing Address - Street 1:PO BOX 24160
Mailing Address - Street 2:
Mailing Address - City:LYNDHURST
Mailing Address - State:OH
Mailing Address - Zip Code:44124-0160
Mailing Address - Country:US
Mailing Address - Phone:216-233-2527
Mailing Address - Fax:
Practice Address - Street 1:3619 PARK EAST DR
Practice Address - Street 2:205 S
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-4330
Practice Address - Country:US
Practice Address - Phone:216-591-0942
Practice Address - Fax:440-834-1902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35073702M207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9361741OtherMEDICARE GROUP
G92217Medicare UPIN