Individual
CHERYL GIBSON FOUNTAIN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
M.D.
Contact information
Practice address
15050 E JEFFERSON AVE, GROSSE POINTE PARK, MI 48230-2050
(313) 823-4682
(313) 823-8022
Mailing address
43800 GARFIELD RD, CLINTON TWP, MI 48038-1136
(800) 848-0202
(586) 226-6949
Taxonomy
Speciality
Code
Description
License number
State
207V00000X
Obstetrics & Gynecology Physician
Primary
4301052473
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
4417616
—
MI
05
—
4502234
—
MI
01
—
700H249730
BCBS GROUP NUMBER
MI
Enumeration date
10/10/2005
Last updated
10/22/2020
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