Provider Demographics
NPI:1134137391
Name:FOSTER FAMILY MEDICINE & ASSOCIATES LLC
Entity Type:Organization
Organization Name:FOSTER FAMILY MEDICINE & ASSOCIATES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:660-263-1513
Mailing Address - Street 1:401 N KEENE ST
Mailing Address - Street 2:MEDICAL NETWORK TECHNOLOGIES
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65201-6625
Mailing Address - Country:US
Mailing Address - Phone:573-874-3300
Mailing Address - Fax:573-876-1601
Practice Address - Street 1:300 N MORLEY ST
Practice Address - Street 2:
Practice Address - City:MOBERLY
Practice Address - State:MO
Practice Address - Zip Code:65270-2334
Practice Address - Country:US
Practice Address - Phone:660-263-1513
Practice Address - Fax:660-263-1795
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-04
Last Update Date:2012-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO101628207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500448204Medicaid
000014673Medicare ID - Type Unspecified
MO500448204Medicaid