=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447397427
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MICHAEL E. FOSTER M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/31/2007
-----------------------------------------------------
Last Update Date | 01/18/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5036 GOODMAN RD SUITE #116
-----------------------------------------------------
City | OLIVE BRANCH
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 38654-7966
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 662-420-7061
-----------------------------------------------------
Fax | 662-420-7583
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 965 RIDGE LAKE BLVD STE 315
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38120-9401
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 11681
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 18383
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------