Provider Demographics
NPI:1487643854
Name:FOUNTAIN, RAETTA B (MD)
Entity Type:Individual
Prefix:MRS
First Name:RAETTA
Middle Name:B
Last Name:FOUNTAIN
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 1:2465 EMERALD PLACE
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5785
Mailing Address - Country:US
Mailing Address - Phone:252-758-2424
Mailing Address - Fax:252-758-0424
Practice Address - Street 1:2465 EMERALD PLACE
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5785
Practice Address - Country:US
Practice Address - Phone:252-758-2424
Practice Address - Fax:252-758-0424
Is Sole Proprietor?:No
Enumeration Date:2005-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00025122207RG0100X
NC9400570207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903770Medicaid
NC2239527BMedicare ID - Type Unspecified
NC5903770Medicaid