MEDICARE: JOHN FONTAINE MD

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	207RC0000X	Cardiovascular Disease Physician	MD042292L	PA
2	207RC0001X	Clinical Cardiac Electrophysiology Physician	MD042292L	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811945017
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHN FONTAINE MD

Provider Business Mailing Address
First Line	:	1601 CHERRY ST
Second Line	:	SUITE 11511
City	:	PHILADELPHIA
State	:	PA
Zip	:	19102-1321
Country	:	US
Telephone Number	:	215-255-7822
Fax Number	:	215-255-7825

Provider Business Practice Location Address
First Line	:	219 N BROAD ST
Second Line	:	2ND FLOOR
City	:	PHILADELPHIA
State	:	PA
Zip	:	19107-1519
Country	:	US
Telephone Number	:	215-762-5080
Fax Number	:	215-561-8071

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	09/13/2016

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Directions to “ JOHN FONTAINE MD” Practice Location

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