Basic Information
| Provider Information | |||||||||
| NPI: | 1346221157 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORE | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | JOHNSON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3601 SW 160TH AVE STE 250 | ||||||||
| Address2: | |||||||||
| City: | MIRAMAR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330276314 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778667123 | ||||||||
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| Practice Location | |||||||||
| Address1: | 105 W STONE DR | ||||||||
| Address2: | SUITE 4A | ||||||||
| City: | KINGSPORT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376603256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233926265 | ||||||||
| FaxNumber: | 4233926272 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/09/2005 | ||||||||
| LastUpdateDate: | 03/15/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | MD0000026800 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 208600000X | MD26800 | TN | N | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 1346221157 | 05 | VA | MEDICAID | 3700364 | 05 | TN | MEDICAID | 3826258 | 05 | TN | MEDICAID |