Provider Demographics
NPI:1689798522
Name:FOSTER, TIMOTHY BRUCE (CO)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:BRUCE
Last Name:FOSTER
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1025 WH SMITH BLVD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:GREENVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27834-5052
Mailing Address - Country:US
Mailing Address - Phone:252-215-2215
Mailing Address - Fax:252-215-2216
Practice Address - Street 1:1025 WH SMITH BLVD
Practice Address - Street 2:SUITE 108
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-5052
Practice Address - Country:US
Practice Address - Phone:252-215-2215
Practice Address - Fax:252-215-2216
Is Sole Proprietor?:No
Enumeration Date:2007-03-17
Last Update Date:2013-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP14092225100000X
KYCO004117222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795522Medicaid