1407275530 NPI number — ERIC FONTAINE

Table of content: ERIC FONTAINE (NPI 1407275530)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407275530 NPI number — ERIC FONTAINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FONTAINE
Provider First Name:
ERIC
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1407275530
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1310 MIDDLEFORD RD
Provider Second Line Business Mailing Address:
SUITE 101
Provider Business Mailing Address City Name:
SEAFORD
Provider Business Mailing Address State Name:
DE
Provider Business Mailing Address Postal Code:
19973-3670
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
302-629-5700
Provider Business Mailing Address Fax Number:
302-629-6001

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1310 MIDDLEFORD RD
Provider Second Line Business Practice Location Address:
SUITE 101
Provider Business Practice Location Address City Name:
SEAFORD
Provider Business Practice Location Address State Name:
DE
Provider Business Practice Location Address Postal Code:
19973-3670
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
302-629-5700
Provider Business Practice Location Address Fax Number:
302-629-6001
Provider Enumeration Date:
04/16/2014

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  J1-0003121 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: K7520021 . This is a "CAREFIRST" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: P01401462 . This is a "RR MEDICARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".
  • Identifier: 1407275530 , issued by the state of ( DE ) . This identifiers is of the category "MEDICAID".
  • Identifier: 346204YBWE . This is a "MEDICARE" identifier , issued by the state of ( DE ) . This identifiers is of the category "OTHER".




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