Provider Demographics
NPI:1215975289
Name:FOREST MEDICAL GROUP, PLLC
Entity type:Organization
Organization Name:FOREST MEDICAL GROUP, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN , OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:F
Authorized Official - Last Name:DIVENCENZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:716-689-4800
Mailing Address - Street 1:1360 N FOREST RD
Mailing Address - Street 2:SUITE 3
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-1200
Mailing Address - Country:US
Mailing Address - Phone:716-689-4800
Mailing Address - Fax:716-689-4816
Practice Address - Street 1:1360 N FOREST RD
Practice Address - Street 2:SUITE 3
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-1200
Practice Address - Country:US
Practice Address - Phone:716-689-4800
Practice Address - Fax:716-689-4816
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2007-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188929-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYAA1024Medicare ID - Type UnspecifiedGROUP