Provider Demographics
NPI:1790856938
Name:FOREST MEDCARE P.C.
Entity Type:Organization
Organization Name:FOREST MEDCARE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JERZY
Authorized Official - Middle Name:
Authorized Official - Last Name:WAWERSKI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-381-3766
Mailing Address - Street 1:6657 FOREST AVE
Mailing Address - Street 2:GROUND FLOOR
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385-3837
Mailing Address - Country:US
Mailing Address - Phone:718-381-3766
Mailing Address - Fax:718-381-3765
Practice Address - Street 1:6050 69TH AVE
Practice Address - Street 2:GROUND FLOOR
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-5140
Practice Address - Country:US
Practice Address - Phone:718-381-3766
Practice Address - Fax:718-381-3765
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-10
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY204587173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02131684Medicaid
NY06979AOtherMEDICARE PTAN
NYH31802Medicare UPIN