Provider Demographics
NPI:1366486235
Name:FOSTER, CHRISTIE (MD)
Entity Type:Individual
Prefix:
First Name:CHRISTIE
Middle Name:
Last Name:FOSTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 S 42ND ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IL
Mailing Address - Zip Code:62864-6216
Mailing Address - Country:US
Mailing Address - Phone:618-315-6360
Mailing Address - Fax:618-315-6356
Practice Address - Street 1:1104 S 42ND ST
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IL
Practice Address - Zip Code:62864-6216
Practice Address - Country:US
Practice Address - Phone:618-315-6360
Practice Address - Fax:618-315-6356
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112920207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL8716001OtherMEDICARE PTAN
IL0361129202Medicaid
ILDU1659OtherRR MEDICARE PTAN
IL0361129202Medicaid
ILK24814Medicare ID - Type Unspecified