1215090683 NPI number — FOUNTAIN SQUARE INTERNAL MEDICINE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1215090683 NPI number — FOUNTAIN SQUARE INTERNAL MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUNTAIN SQUARE INTERNAL MEDICINE
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

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:
1215090683
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/28/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1315 2ND ST SW
Provider Second Line Business Mailing Address:
STE 101
Provider Business Mailing Address City Name:
ROANOKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
24016-4935
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
540-344-5550
Provider Business Mailing Address Fax Number:
540-344-5205

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1315 2ND ST SW
Provider Second Line Business Practice Location Address:
STE 101
Provider Business Practice Location Address City Name:
ROANOKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24016-4935
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
540-344-5550
Provider Business Practice Location Address Fax Number:
540-344-5205
Provider Enumeration Date:
12/18/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MALPASS
Authorized Official First Name:
MICHAEL
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
540-344-5550

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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