Provider Demographics
NPI:1568410421
Name:FORESTHILL MEDICAL CENTER INC
Entity Type:Organization
Organization Name:FORESTHILL MEDICAL CENTER INC
Other - Org Name:BLAISE DESOUZA MD
Other - Org Type:Other Name
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BLAISE
Authorized Official - Middle Name:PHILIP
Authorized Official - Last Name:DESOUZA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:530-367-2229
Mailing Address - Street 1:PO BOX 1040
Mailing Address - Street 2:
Mailing Address - City:FORESTHILL
Mailing Address - State:CA
Mailing Address - Zip Code:95631-1040
Mailing Address - Country:US
Mailing Address - Phone:530-367-2229
Mailing Address - Fax:530-367-4161
Practice Address - Street 1:23000 FORESTHILL RD
Practice Address - Street 2:
Practice Address - City:FORESTHILL
Practice Address - State:CA
Practice Address - Zip Code:95631
Practice Address - Country:US
Practice Address - Phone:530-367-2229
Practice Address - Fax:530-367-4161
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA37917208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA5362017Medicaid
A28485Medicare UPIN
CA5362017Medicaid