MEDICARE: FOUNTAIN SQUARE INTERNAL MEDICINE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician

General Provider Information

NPI Number	:	1215090683
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUNTAIN SQUARE INTERNAL MEDICINE

Provider Business Mailing Address
First Line	:	1315 2ND ST SW
Second Line	:	STE 101
City	:	ROANOKE
State	:	VA
Zip	:	24016-4935
Country	:	US
Telephone Number	:	540-344-5550
Fax Number	:	540-344-5205

Provider Business Practice Location Address
First Line	:	1315 2ND ST SW
Second Line	:	STE 101
City	:	ROANOKE
State	:	VA
Zip	:	24016-4935
Country	:	US
Telephone Number	:	540-344-5550
Fax Number	:	540-344-5205

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. MICHAEL ALAN MALPASS
Credential	:	M.D.
Telephone Number	:	540-344-5550

Provider Enumeration Date	:	12/18/2006
Last Update Date	:	01/28/2010

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