Basic Information
| Provider Information | |||||||||
| NPI: | 1902127756 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORKE | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | PAUL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 406 1ST AVE S | ||||||||
| Address2: | |||||||||
| City: | LEWISTOWN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594573020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065356545 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 406 1ST AVE S | ||||||||
| Address2: | |||||||||
| City: | LEWISTOWN | ||||||||
| State: | MT | ||||||||
| PostalCode: | 594573020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4065356545 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2010 | ||||||||
| LastUpdateDate: | 04/05/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 25924 | MT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1902127756 | 05 | MT | MEDICAID | 924810 | 01 | MT | BLUE CROSS BLUE SHIELD | OTHER |