Healthcare Provider Details

I. General information

NPI: 1386984425
Provider Name (Legal Business Name): GARY BRUCE FOSTER JR. REGISTERED NURSE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/27/2013
Last Update Date: 02/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41250 BUTTERNUT RIDGE RD
ELYRIA OH
44035-7431
US

IV. Provider business mailing address

7100 FIRESTONE RD
SPENCER OH
44275-9540
US

V. Phone/Fax

Practice location:
  • Phone: 440-458-4183
  • Fax:
Mailing address:
  • Phone: 330-635-9244
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number339799
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: