Basic Information
| Provider Information | |||||||||
| NPI: | 1396789830 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EASLEY | ||||||||
| FirstName: | S FOSTER | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | EASLEY | ||||||||
| OtherFirstName: | FOSTER | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1530 W. GLENDALE AVE | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029738285 | ||||||||
| FaxNumber: | 6029738248 | ||||||||
| Practice Location | |||||||||
| Address1: | 1530 W. GLENDALE AVE. | ||||||||
| Address2: | SUITE 104 | ||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 85021 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029738285 | ||||||||
| FaxNumber: | 6029738248 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 01/08/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 3212 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine | 207QA0401X | 3212 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine | Addiction Medicine | 207RA0401X | 3212 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Addiction Medicine | 207RI0200X | 3212 | AZ | N | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
ID Information
| ID | Type | State | Issuer | Description | 579170 | 05 | AZ | MEDICAID |