Provider Demographics
NPI:1215257837
Name:FOUNTAIN MEDICAL ASSOCIATES P C
Entity type:Organization
Organization Name:FOUNTAIN MEDICAL ASSOCIATES P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SAFIYYA
Authorized Official - Middle Name:S
Authorized Official - Last Name:SHABAZZ
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:215-924-2440
Mailing Address - Street 1:22 E MOUNT AIRY AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19119-1712
Mailing Address - Country:US
Mailing Address - Phone:215-924-2440
Mailing Address - Fax:267-437-2346
Practice Address - Street 1:22 E MOUNT AIRY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19119
Practice Address - Country:US
Practice Address - Phone:215-924-2440
Practice Address - Fax:267-437-2346
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-04
Last Update Date:2018-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD428070207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty