Provider Demographics
NPI:1730425851
Name:FOUNTAIN HEALTHCARE LIMITED LIABILITY COMPANY
Entity type:Organization
Organization Name:FOUNTAIN HEALTHCARE LIMITED LIABILITY COMPANY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:WARGO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-793-6611
Mailing Address - Street 1:1639 N 1590TH RD
Mailing Address - Street 2:
Mailing Address - City:STREATOR
Mailing Address - State:IL
Mailing Address - Zip Code:61364-9644
Mailing Address - Country:US
Mailing Address - Phone:815-793-6611
Mailing Address - Fax:630-592-7500
Practice Address - Street 1:1639 N 1590TH RD
Practice Address - Street 2:
Practice Address - City:STREATOR
Practice Address - State:IL
Practice Address - Zip Code:61364-9644
Practice Address - Country:US
Practice Address - Phone:815-793-6611
Practice Address - Fax:630-592-7500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036099987207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Multi-Specialty