Provider Demographics
NPI:1417418724
Name:HYDRXAFUSE, LLC
Entity Type:Organization
Organization Name:HYDRXAFUSE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:TOWANNA
Authorized Official - Middle Name:
Authorized Official - Last Name:FONTENOT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:443-699-0321
Mailing Address - Street 1:49 OLD SOLOMONS ISLAND RD STE 104
Mailing Address - Street 2:
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3861
Mailing Address - Country:US
Mailing Address - Phone:443-699-0321
Mailing Address - Fax:
Practice Address - Street 1:49 OLD SOLOMONS ISLAND RD STE 104
Practice Address - Street 2:
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3861
Practice Address - Country:US
Practice Address - Phone:443-699-0321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-28
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion TherapyGroup - Multi-Specialty