Basic Information
| Provider Information | |||||||||
| NPI: | 1972504355 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FONTANE | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 44008 | ||||||||
| Address2: | UFJP PROVIDER ENROLLMENT | ||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042443660 | ||||||||
| FaxNumber: | 9042443425 | ||||||||
| Practice Location | |||||||||
| Address1: | 655 W 8TH STREET | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9042445044 | ||||||||
| FaxNumber: | 9042444508 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/09/2005 | ||||||||
| LastUpdateDate: | 03/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0203X | D67938 | MD | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Critical Care Medicine | 2080P0204X | D67938 | MD | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine | 207P00000X | ME99702 | FL | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 279794101 | 05 | FL | MEDICAID | 415631500 | 05 | MD | MEDICAID | 003105963A | 05 | GA | MEDICAID | 89129EX | 05 | NC | MEDICAID | 930109142 | 01 | NC | RAILROAD MEDICARE | OTHER | 129EX | 01 | NC | BCBS NC | OTHER |