Provider Demographics
NPI:1992777171
Name:FOUNTAIN MEDICAL GROUP SC
Entity type:Organization
Organization Name:FOUNTAIN MEDICAL GROUP SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWIN
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:CAREY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-786-2101
Mailing Address - Street 1:15 W PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:SANDWICH
Mailing Address - State:IL
Mailing Address - Zip Code:60548-1050
Mailing Address - Country:US
Mailing Address - Phone:815-786-2101
Mailing Address - Fax:815-786-7745
Practice Address - Street 1:15 W PLEASANT AVE
Practice Address - Street 2:
Practice Address - City:SANDWICH
Practice Address - State:IL
Practice Address - Zip Code:60548-1050
Practice Address - Country:US
Practice Address - Phone:815-786-2101
Practice Address - Fax:815-786-7745
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty