Provider Demographics
NPI:1639622236
Name:FORDEM HEALTH, LLC
Entity Type:Organization
Organization Name:FORDEM HEALTH, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:JOHN
Authorized Official - Last Name:FOREIT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:877-757-2568
Mailing Address - Street 1:730 45TH AVE
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-2818
Mailing Address - Country:US
Mailing Address - Phone:877-757-2568
Mailing Address - Fax:
Practice Address - Street 1:1313 PARK DR
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-2634
Practice Address - Country:US
Practice Address - Phone:877-757-2568
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-31
Last Update Date:2020-10-28
Deactivation Date:2020-10-05
Deactivation Code:
Reactivation Date:2020-10-28
Provider Licenses
StateLicense IDTaxonomies
IN02001522261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1376740647OtherNPI NUMBER
256390COtherMEDICARE #
256390COtherMEDICARE #