Provider Demographics
NPI:1437224243
Name:FORSYTH FAMILY MEDICINE PC
Entity Type:Organization
Organization Name:FORSYTH FAMILY MEDICINE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:JANE
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:DEERING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:406-346-2916
Mailing Address - Street 1:PO BOX 410
Mailing Address - Street 2:281 N 17TH AVENUE
Mailing Address - City:FORSYTH
Mailing Address - State:MT
Mailing Address - Zip Code:59327-0410
Mailing Address - Country:US
Mailing Address - Phone:406-346-2916
Mailing Address - Fax:406-346-7478
Practice Address - Street 1:281 N 17TH AVENUE
Practice Address - Street 2:
Practice Address - City:FORSYTH
Practice Address - State:MT
Practice Address - Zip Code:59327-0410
Practice Address - Country:US
Practice Address - Phone:406-346-2916
Practice Address - Fax:406-346-7478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-21
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT4811261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTCJ4988OtherRAILROAD MEDICARE EDI #
MT0053329Medicaid