Provider Demographics
NPI:1508822420
Name:FREETH-FOUNTAIN, AMY ELIZABETH (MD)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:ELIZABETH
Last Name:FREETH-FOUNTAIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:AMY
Other - Middle Name:ELIZABETH
Other - Last Name:FOUNTAIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:413 MIDDLE GROVE LN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28411-4402
Mailing Address - Country:US
Mailing Address - Phone:607-354-9934
Mailing Address - Fax:
Practice Address - Street 1:413 MIDDLE GROVE LN
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28411-4402
Practice Address - Country:US
Practice Address - Phone:607-435-9934
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2025-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215894207R00000X, 207RE0101X
NC2024-01118207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02569419Medicaid
NYI11782Medicare UPIN
NYRA2536Medicare ID - Type UnspecifiedUPSTATE