1316266414 NPI number — MR. BRIAN FOSTER I

Table of content: MR. BRIAN FOSTER I (NPI 1316266414)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316266414 NPI number — MR. BRIAN FOSTER I

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FOSTER
Provider First Name:
BRIAN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
I
Provider Credential Text:
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1316266414
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/09/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
322 DUNCAN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATOKA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38004-7875
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-837-9583
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1900 EXETER RD
Provider Second Line Business Practice Location Address:
SUITE 210
Provider Business Practice Location Address City Name:
GERMANTOWN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38138-2954
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-818-2183
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/28/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  APN 15231 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163W00000X , with the licence number: RN0000135168 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1521696 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 05656310 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1316266414 . This is a "CHAMPUS/HUMANA TRICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4274309 . This is a "BLUE CROSS" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 186483001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00907123 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".




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