Provider Demographics
NPI:1215090683
Name:FOUNTAIN SQUARE INTERNAL MEDICINE
Entity type:Organization
Organization Name:FOUNTAIN SQUARE INTERNAL MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:MALPASS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:540-344-5550
Mailing Address - Street 1:1315 2ND ST SW
Mailing Address - Street 2:STE 101
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4935
Mailing Address - Country:US
Mailing Address - Phone:540-344-5550
Mailing Address - Fax:540-344-5205
Practice Address - Street 1:1315 2ND ST SW
Practice Address - Street 2:STE 101
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4935
Practice Address - Country:US
Practice Address - Phone:540-344-5550
Practice Address - Fax:540-344-5205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC09792Medicare ID - Type Unspecified