Basic Information
| Provider Information | |||||||||
| NPI: | 1063687507 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | J. MICHAEL FORREST MD PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7420 NW 5TH ST | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333171611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545836311 | ||||||||
| FaxNumber: | 9545836492 | ||||||||
| Practice Location | |||||||||
| Address1: | 7420 NW 5TH ST | ||||||||
| Address2: | SUITE 105 | ||||||||
| City: | PLANTATION | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333171611 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545836311 | ||||||||
| FaxNumber: | 9545836492 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2008 | ||||||||
| LastUpdateDate: | 04/25/2008 | ||||||||
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| AuthorizedOfficialLastName: | FORREST | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | MICHAEL | ||||||||
| AuthorizedOfficialTitleorPosition: | PHYSICIAN | ||||||||
| AuthorizedOfficialTelephone: | 9545836311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | ME0062996 | FL | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | 375981400 | 05 | FL | MEDICAID |