Basic Information
| Provider Information | |||||||||
| NPI: | 1407275530 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | FONTAINE | ||||||||
| FirstName: | ERIC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1310 MIDDLEFORD RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SEAFORD | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199733670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026295700 | ||||||||
| FaxNumber: | 3026296001 | ||||||||
| Practice Location | |||||||||
| Address1: | 1310 MIDDLEFORD RD | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | SEAFORD | ||||||||
| State: | DE | ||||||||
| PostalCode: | 199733670 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026295700 | ||||||||
| FaxNumber: | 3026296001 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/16/2014 | ||||||||
| LastUpdateDate: | 02/24/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | J1-0003121 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | K7520021 | 01 | DE | CAREFIRST | OTHER | P01401462 | 01 | DE | RR MEDICARE | OTHER | 1407275530 | 05 | DE | MEDICAID | 346204YBWE | 01 | DE | MEDICARE | OTHER |