Provider Demographics
NPI:1902829567
Name:FOSTER, NOVA MICHELE (MD)
Entity Type:Individual
Prefix:
First Name:NOVA
Middle Name:MICHELE
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:PO BOX 1105
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46206-1105
Mailing Address - Country:US
Mailing Address - Phone:618-457-5200
Mailing Address - Fax:618-351-6486
Practice Address - Street 1:1237 E MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-3148
Practice Address - Country:US
Practice Address - Phone:618-457-2281
Practice Address - Fax:618-529-0573
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2014-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA65913208600000X
IL036.134717208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A659130Medicaid
CAWA65913AMedicare PIN
CAH91005Medicare UPIN
CACF028ZMedicare PIN
IL214881Medicare Oscar/Certification