Provider Demographics
NPI:1336636158
Name:FOUNDATION MEDICAL, INC.
Entity Type:Organization
Organization Name:FOUNDATION MEDICAL, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FACILITY DIRECTOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:TEAGUE
Authorized Official - Last Name:GOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-202-3008
Mailing Address - Street 1:1730 OLD GRAY STATION RD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-3869
Mailing Address - Country:US
Mailing Address - Phone:423-202-3008
Mailing Address - Fax:423-202-7835
Practice Address - Street 1:1730 OLD GRAY STATION RD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37615-3869
Practice Address - Country:US
Practice Address - Phone:423-202-3008
Practice Address - Fax:423-202-7835
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-17
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1000000022019207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Single Specialty