Provider Demographics
NPI:1467424853
Name:FOUNTAIN-ELLIS, TAMI (MD)
Entity Type:Individual
Prefix:DR
First Name:TAMI
Middle Name:
Last Name:FOUNTAIN-ELLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9600 PATTERSON AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23229-6053
Mailing Address - Country:US
Mailing Address - Phone:804-741-6200
Mailing Address - Fax:804-741-6213
Practice Address - Street 1:9600 PATTERSON AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23229-6053
Practice Address - Country:US
Practice Address - Phone:804-741-6200
Practice Address - Fax:804-741-6213
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2020-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101102532207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA080190627OtherMEDICARE RAILROAD
VA010075823Medicaid
VA292416OtherANTHEM
VAC06695OtherGROUP PTAN
VAC06695OtherGROUP PTAN