Provider Demographics
NPI:1043859630
Name:BEV FONTAINE LLC
Entity Type:Organization
Organization Name:BEV FONTAINE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:HOSSIEN
Authorized Official - Middle Name:
Authorized Official - Last Name:TALEBIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:703-955-4923
Mailing Address - Street 1:1410 POWELLS TAVERN PL
Mailing Address - Street 2:
Mailing Address - City:HERNDON
Mailing Address - State:VA
Mailing Address - Zip Code:20170-5712
Mailing Address - Country:US
Mailing Address - Phone:703-955-4923
Mailing Address - Fax:703-444-3610
Practice Address - Street 1:5550 FRIENDSHIP BLVD STE 360
Practice Address - Street 2:
Practice Address - City:CHEVY CHASE
Practice Address - State:MD
Practice Address - Zip Code:20815-7256
Practice Address - Country:US
Practice Address - Phone:240-341-1290
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-30
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDD85002OtherMARYLAND PHYSICIAN LICENSE
MDM94766OtherCDS REGISTRATION
VA0101265585OtherVIRGINIA PHYSICIAN LICENSE
DCMD042654OtherDC PHYSICIAN LICENSE
DCMD042654OtherDC PHYSICIAN LICENSE