Healthcare Provider Details

I. General information

NPI: 1407883382
Provider Name (Legal Business Name): JEREMIAH THOMAS FOSTER ATC, C.S.C.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

360 HUNTINGTON AVE 140 MARINO CENTER
BOSTON MA
02115-5005
US

IV. Provider business mailing address

4 REYNOLDS RD
PEABODY MA
01960-1613
US

V. Phone/Fax

Practice location:
  • Phone: 617-373-7766
  • Fax: 617-373-8278
Mailing address:
  • Phone: 978-531-9453
  • Fax: 617-373-8278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT-76
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: