Provider Demographics
NPI:1154834562
Name:FOUNTAIN ANTI-AGING
Entity Type:Organization
Organization Name:FOUNTAIN ANTI-AGING
Other - Org Name:XRMD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHAIRMAN
Authorized Official - Prefix:
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:ROZAKIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-233-8503
Mailing Address - Street 1:892 BEACH RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44107-1018
Mailing Address - Country:US
Mailing Address - Phone:216-233-8503
Mailing Address - Fax:
Practice Address - Street 1:892 BEACH RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:OH
Practice Address - Zip Code:44107-1018
Practice Address - Country:US
Practice Address - Phone:216-233-8503
Practice Address - Fax:216-373-0044
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY243058-1207W00000X
CAG142755207W00000X
CT56673207W00000X
PAMD459908207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0655189Medicaid