Provider Demographics
NPI:1124228119
Name:FOUNTAIN FAMILY MEDICINE, PA
Entity Type:Organization
Organization Name:FOUNTAIN FAMILY MEDICINE, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LEANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:MACDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-262-9075
Mailing Address - Street 1:11701-32 SAN JOSE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32223
Mailing Address - Country:US
Mailing Address - Phone:904-262-9075
Mailing Address - Fax:
Practice Address - Street 1:11701-32 SAN JOSE BOULEVARD
Practice Address - Street 2:SUITE 103
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223
Practice Address - Country:US
Practice Address - Phone:904-262-9075
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-19
Last Update Date:2012-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK8630Medicare PIN