1902816051 NPI number — FOUNTAIN PULMONARY P.C

Table of content: (NPI 1902816051)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902816051 NPI number — FOUNTAIN PULMONARY P.C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUNTAIN PULMONARY P.C
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:
1902816051
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/16/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
800 MANOR RD
Provider Second Line Business Mailing Address:
SUITE 3
Provider Business Mailing Address City Name:
STATEN ISLAND
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10314-7034
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-562-2753
Provider Business Mailing Address Fax Number:
347-289-5100

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 MANOR RD
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
STATEN ISLAND
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10314-7034
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-562-2753
Provider Business Practice Location Address Fax Number:
347-289-5100
Provider Enumeration Date:
08/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
OLAJITAN
Authorized Official First Name:
ADEBAMBO
Authorized Official Middle Name:
DOLAPO
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
347-562-2753

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  212276 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01883816 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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