Provider Demographics
NPI:1740419688
Name:FOUNTAIN, KIMBERLY TERESA (MD,MS)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:TERESA
Last Name:FOUNTAIN
Suffix:
Gender:F
Credentials:MD,MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 RAILROAD AVE
Mailing Address - Street 2:STE 1-D
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-3782
Mailing Address - Country:US
Mailing Address - Phone:801-671-0933
Mailing Address - Fax:
Practice Address - Street 1:GRU
Practice Address - Street 2:1120 15TH STREET
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0001
Practice Address - Country:US
Practice Address - Phone:706-834-0190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-14
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN207R0000X207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine