Basic Information
| Provider Information | |||||||||
| NPI: | 1932389061 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOSTER | ||||||||
| FirstName: | MARK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 567 BLAUVELT RD | ||||||||
| Address2: | |||||||||
| City: | PEARL RIVER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109652848 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 599 CONVENT ROAD | ||||||||
| Address2: | |||||||||
| City: | ORANGEBURG | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109621199 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453591000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2007 | ||||||||
| LastUpdateDate: | 11/06/2007 | ||||||||
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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 | 2084P0800X | 157521 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 157521 | 05 | NY | MEDICAID |