Healthcare Provider Details

I. General information

NPI: 1417418724
Provider Name (Legal Business Name): HYDRXAFUSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2019
Last Update Date: 05/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

49 OLD SOLOMONS ISLAND RD STE 104
ANNAPOLIS MD
21401-3861
US

IV. Provider business mailing address

49 OLD SOLOMONS ISLAND RD STE 104
ANNAPOLIS MD
21401-3861
US

V. Phone/Fax

Practice location:
  • Phone: 443-699-0321
  • Fax:
Mailing address:
  • Phone: 443-699-0321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. TOWANNA FONTENOT
Title or Position: MEDICAL DIRECTOR/PHYSICIAN
Credential: MD
Phone: 443-699-0321