Provider Demographics
NPI:1346221157
Name:FORE, EDWARD JOHNSON (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JOHNSON
Last Name:FORE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3601 SW 160TH AVE STE 250
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-6314
Mailing Address - Country:US
Mailing Address - Phone:877-866-7123
Mailing Address - Fax:
Practice Address - Street 1:105 W STONE DR
Practice Address - Street 2:SUITE 4A
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3256
Practice Address - Country:US
Practice Address - Phone:423-392-6265
Practice Address - Fax:423-392-6272
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2018-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000026800207Q00000X
TNMD26800208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1346221157Medicaid
TN3700364Medicaid
TN3826258Medicaid
VA1346221157Medicaid
TN3700592Medicare UPIN
TN103I086169Medicare UPIN
TN3700364Medicaid
TN38262501Medicare UPIN