Provider Demographics
NPI:1528379831
Name:FOSTER, MICHAEL WARREN (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:WARREN
Last Name:FOSTER
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 1:2500 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4500
Mailing Address - Country:US
Mailing Address - Phone:601-984-5200
Mailing Address - Fax:601-984-2086
Practice Address - Street 1:1225 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2064
Practice Address - Country:US
Practice Address - Phone:601-968-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-01
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21829208000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS08174256Medicaid
MS08174256Medicaid