Provider Demographics
NPI:1235119181
Name:FOREST FAMILY PRACTICE CLINIC PA
Entity Type:Organization
Organization Name:FOREST FAMILY PRACTICE CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-469-4861
Mailing Address - Street 1:PO BOX 600
Mailing Address - Street 2:
Mailing Address - City:FOREST
Mailing Address - State:MS
Mailing Address - Zip Code:39074-0600
Mailing Address - Country:US
Mailing Address - Phone:601-469-4861
Mailing Address - Fax:601-469-4828
Practice Address - Street 1:1 MEDICAL LN
Practice Address - Street 2:
Practice Address - City:FOREST
Practice Address - State:MS
Practice Address - Zip Code:39074-4039
Practice Address - Country:US
Practice Address - Phone:601-469-4861
Practice Address - Fax:601-469-4828
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-18
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS05638207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09014143Medicaid
MS253923Medicare ID - Type Unspecified
MSB30937Medicare UPIN
MSB30234Medicare UPIN
MSB30908Medicare UPIN
MSS29075Medicare UPIN
MS09014143Medicaid