Healthcare Provider Details

I. General information

NPI: 1134137391
Provider Name (Legal Business Name): FOSTER FAMILY MEDICINE & ASSOCIATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/04/2006
Last Update Date: 09/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 N MORLEY ST
MOBERLY MO
65270-2334
US

IV. Provider business mailing address

401 N KEENE ST MEDICAL NETWORK TECHNOLOGIES
COLUMBIA MO
65201-6625
US

V. Phone/Fax

Practice location:
  • Phone: 660-263-1513
  • Fax: 660-263-1795
Mailing address:
  • Phone: 573-874-3300
  • Fax: 573-876-1601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number101628
License Number StateMO

VIII. Authorized Official

Name: RANDY ALAN FOSTER
Title or Position: PRESIDENT
Credential: D.O.
Phone: 660-263-1513