=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003849597
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FATUMA MIDAMBA MD INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/08/2006
-----------------------------------------------------
Last Update Date | 09/19/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3619 PARK EAST DR 205 S
-----------------------------------------------------
City | BEACHWOOD
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44122-4330
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-591-0942
-----------------------------------------------------
Fax | 440-834-1902
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 24160
-----------------------------------------------------
City | LYNDHURST
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 44124-0160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 216-233-2527
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. FATUMA MIDAMBA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 440-834-1833
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 35073702M
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------