Provider Demographics
NPI:1891029823
Name:FOUNTAIN HEALTH, LLC
Entity Type:Organization
Organization Name:FOUNTAIN HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:LAURA
Authorized Official - Middle Name:WATTS
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:301-698-5050
Mailing Address - Street 1:15 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:FREDERICK
Mailing Address - State:MD
Mailing Address - Zip Code:21701-4501
Mailing Address - Country:US
Mailing Address - Phone:301-698-5050
Mailing Address - Fax:301-698-4652
Practice Address - Street 1:15 W 7TH ST
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21701-4501
Practice Address - Country:US
Practice Address - Phone:301-698-5050
Practice Address - Fax:301-698-4652
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-23
Last Update Date:2009-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0037197207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDS62405Medicare UPIN
MDA72167Medicare UPIN