Healthcare Provider Details

I. General information

NPI: 1083886915
Provider Name (Legal Business Name): FOUNTAIN CITY MEDICAL CLINIC INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2008
Last Update Date: 04/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 W HIGH ST
BRYAN OH
43506-1614
US

IV. Provider business mailing address

324 W HIGH ST
BRYAN OH
43506-1614
US

V. Phone/Fax

Practice location:
  • Phone: 419-636-2525
  • Fax: 419-636-0632
Mailing address:
  • Phone: 419-636-2525
  • Fax: 419-636-0632

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number35033085
License Number StateOH

VIII. Authorized Official

Name: PEDRITO A GALUPO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 419-636-2525