=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831291376
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MELISSA ANNE FOROUHAR MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2006
-----------------------------------------------------
Last Update Date | 12/29/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | MADIGAN ARMY MEDICAL CTR 9040 JACKSON AVE
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98431-1110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-968-1110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | MADIGAN ARMY MEDICAL CTR 9040 JACKSON AVE
-----------------------------------------------------
City | TACOMA
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98431-1110
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 253-968-1110
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171000000X
-----------------------------------------------------
Taxonomy Name | Military Health Care Provider
-----------------------------------------------------
License Number | 35080075
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2080P0207X
-----------------------------------------------------
Taxonomy Name | Pediatric Hematology & Oncology Physician
-----------------------------------------------------
License Number | MD60949136
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------