Provider Demographics
NPI: | 1376584987 |
---|---|
Name: | FORESTER, MARY A (DO) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | MARY |
Middle Name: | A |
Last Name: | FORESTER |
Suffix: | |
Gender: | F |
Credentials: | DO |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 9601 TOWNLINE RD |
Mailing Address - Street 2: | MARSHFIELD CLINIC |
Mailing Address - City: | MINOCQUA |
Mailing Address - State: | WI |
Mailing Address - Zip Code: | 54548-9099 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 715-358-1000 |
Mailing Address - Fax: | 715-358-1331 |
Practice Address - Street 1: | 9601 TOWNLINE RD |
Practice Address - Street 2: | MARSHFIELD CLINIC |
Practice Address - City: | MINOCQUA |
Practice Address - State: | WI |
Practice Address - Zip Code: | 54548-9099 |
Practice Address - Country: | US |
Practice Address - Phone: | 715-358-1000 |
Practice Address - Fax: | 715-358-1331 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-08 |
Last Update Date: | 2011-10-12 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
WI | 40540-021 | 2084N0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
WI | 30088400 | Medicaid | |
WI | P00050904 | Medicare PIN | |
WI | 30088400 | Medicaid | |
WI | 083574150 | Medicare PIN | |
WI | 032954340 | Medicare PIN | |
F86931 | Medicare UPIN |