Provider Demographics
NPI:1104003086
Name:FORREST FAMILY PRACTICE CENTER LLC
Entity Type:Organization
Organization Name:FORREST FAMILY PRACTICE CENTER LLC
Other - Org Name:FORREST FAMILY PRACTICE LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BENJAMIN
Authorized Official - Middle Name:E
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:815-657-8707
Mailing Address - Street 1:122 E WABASH AVE
Mailing Address - Street 2:P O BOX 58
Mailing Address - City:FORREST
Mailing Address - State:IL
Mailing Address - Zip Code:61741
Mailing Address - Country:US
Mailing Address - Phone:815-657-8707
Mailing Address - Fax:815-657-8717
Practice Address - Street 1:122 E WABASH AVE
Practice Address - Street 2:
Practice Address - City:FORREST
Practice Address - State:IL
Practice Address - Zip Code:61741
Practice Address - Country:US
Practice Address - Phone:815-657-8707
Practice Address - Fax:815-657-8717
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GIBSON COMMUNITY HOSPITAL ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-01-23
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL364468162001Medicaid
IL364468162001Medicaid