1528123668 NPI number — DR. FONTAINE MICHELE EWELL PHD

Table of content: DR. FONTAINE MICHELE EWELL PHD (NPI 1528123668)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528123668 NPI number — DR. FONTAINE MICHELE EWELL PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EWELL
Provider First Name:
FONTAINE
Provider Middle Name:
MICHELE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

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:
1528123668
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
711 W 40TH ST
Provider Second Line Business Mailing Address:
THE ROTUNDA SUITE 456B
Provider Business Mailing Address City Name:
BALTIMORE
Provider Business Mailing Address State Name:
MD
Provider Business Mailing Address Postal Code:
21211-2120
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
410-274-5911
Provider Business Mailing Address Fax Number:
410-235-9339

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
711 W 40TH ST
Provider Second Line Business Practice Location Address:
THE ROTUNDA SUITE 456B
Provider Business Practice Location Address City Name:
BALTIMORE
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
21211-2120
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
410-274-5911
Provider Business Practice Location Address Fax Number:
410-235-9339
Provider Enumeration Date:
12/27/2006

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: 103TC0700X , with the licence number:  04047 , registered in the state of MD ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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