Healthcare Provider Details

I. General information

NPI: 1336636158
Provider Name (Legal Business Name): FOUNDATION MEDICAL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2018
Last Update Date: 07/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1730 OLD GRAY STATION RD
JOHNSON CITY TN
37615-3869
US

IV. Provider business mailing address

1730 OLD GRAY STATION RD
JOHNSON CITY TN
37615-3869
US

V. Phone/Fax

Practice location:
  • Phone: 423-202-3008
  • Fax: 423-202-7835
Mailing address:
  • Phone: 423-202-3008
  • Fax: 423-202-7835

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number1000000022019
License Number StateTN

VIII. Authorized Official

Name: JENNIFER TEAGUE GOOD
Title or Position: FACILITY DIRECTOR/OWNER
Credential:
Phone: 423-202-3008