Provider Demographics
NPI:1063687507
Name:J. MICHAEL FORREST MD PA
Entity Type:Organization
Organization Name:J. MICHAEL FORREST MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:FORREST
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-583-6311
Mailing Address - Street 1:7420 NW 5TH ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33317-1611
Mailing Address - Country:US
Mailing Address - Phone:954-583-6311
Mailing Address - Fax:954-583-6492
Practice Address - Street 1:7420 NW 5TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33317-1611
Practice Address - Country:US
Practice Address - Phone:954-583-6311
Practice Address - Fax:954-583-6492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-25
Last Update Date:2008-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0062996261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL375981400Medicaid
FL375981400Medicaid
FLF84807Medicare UPIN