MEDICARE: DR. BRIAN KEITH FOUTCH O.D.

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	152W00000X	Optometrist	5978T	TX

General Provider Information

NPI Number	:	1376612309
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRIAN KEITH FOUTCH O.D.

Provider Business Mailing Address
First Line	:	101 BARNETT DR
Second Line	:
City	:	EDWARDSVILLE
State	:	IL
Zip	:	62025-2401
Country	:	US
Telephone Number	:	618-581-9392
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 UNIVERSITY BLVD
Second Line	:	331 MARILLAC HALL, UMSL COLLEGE OF OPTOMETRY
City	:	SAINT LOUIS
State	:	MO
Zip	:	63121-4400
Country	:	US
Telephone Number	:	314-516-5499
Fax Number	:

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

Provider Enumeration Date	:	11/06/2006
Last Update Date	:	07/08/2007

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