Provider Demographics
NPI:1154393106
Name:FRED M FOSS, MD
Entity type:Organization
Organization Name:FRED M FOSS, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:WOODS
Authorized Official - Last Name:CONWAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:509-946-8985
Mailing Address - Street 1:948 STEVENS DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-3547
Mailing Address - Country:US
Mailing Address - Phone:509-946-5150
Mailing Address - Fax:509-946-6547
Practice Address - Street 1:948 STEVENS DR
Practice Address - Street 2:SUITE A
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3547
Practice Address - Country:US
Practice Address - Phone:509-946-5150
Practice Address - Fax:509-946-6547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-03
Last Update Date:2009-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00021421208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7115439Medicaid
WA7115439Medicaid