Provider Demographics
NPI:1053300277
Name:WAIDE, FORREST L (BEN) (PT, OCS, CHT)
Entity Type:Individual
Prefix:
First Name:FORREST
Middle Name:L (BEN)
Last Name:WAIDE
Suffix:
Gender:M
Credentials:PT, OCS, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2228 ANTON RD
Mailing Address - Street 2:
Mailing Address - City:MADISONVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42431-7700
Mailing Address - Country:US
Mailing Address - Phone:270-399-1776
Mailing Address - Fax:270-440-2007
Practice Address - Street 1:2228 ANTON RD
Practice Address - Street 2:
Practice Address - City:MADISONVILLE
Practice Address - State:KY
Practice Address - Zip Code:42431-7700
Practice Address - Country:US
Practice Address - Phone:270-399-1776
Practice Address - Fax:270-440-2007
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY001533225100000X
KY100110300542251H1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251H1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000477215OtherANTHEM BCBS FACET #
KY00017001Medicare PIN