Provider Demographics
NPI:1710249537
Name:FOUNDATION MEDICAL SERVICES PA
Entity Type:Organization
Organization Name:FOUNDATION MEDICAL SERVICES PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:GONDOLFO
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:302-730-1101
Mailing Address - Street 1:230 BEISER BLVD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19904-7793
Mailing Address - Country:US
Mailing Address - Phone:302-730-1101
Mailing Address - Fax:
Practice Address - Street 1:230 BEISER BLVD
Practice Address - Street 2:SUITE 101
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19904-7793
Practice Address - Country:US
Practice Address - Phone:302-730-1101
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-08
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEF1-0000323111N00000X
DEC2-0005927207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE248052Medicare PIN