Provider Demographics
NPI:1265727309
Name:KEVIN FORSYTHE MD INC
Entity type:Organization
Organization Name:KEVIN FORSYTHE MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:C
Authorized Official - Last Name:FORSYTHE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-952-5723
Mailing Address - Street 1:1111 LAS TABLAS ROAD SUITE R
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:CA
Mailing Address - Zip Code:93465-3742
Mailing Address - Country:US
Mailing Address - Phone:805-286-4416
Mailing Address - Fax:888-216-9538
Practice Address - Street 1:1111 LAS TABLAS ROAD SUITE R
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-3742
Practice Address - Country:US
Practice Address - Phone:805-286-4416
Practice Address - Fax:888-216-9538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA96098207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10507OtherCITY OF PASO ROBLES BUSINESS LICENSE
CAC3375536OtherSECRETARY OF STATE CORPORATION NUMBER
CAC3375536OtherSECRETARY OF STATE CORPORATION NUMBER
CA6574880001Medicare NSC