Healthcare Provider Details

I. General information

NPI: 1154305738
Provider Name (Legal Business Name): LESLIE B FORGOSH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 03/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 10TH ST W
SAINT PAUL MN
55102-1062
US

IV. Provider business mailing address

45 10TH ST W
SAINT PAUL MN
55102-1062
US

V. Phone/Fax

Practice location:
  • Phone: 651-232-3000
  • Fax:
Mailing address:
  • Phone: 651-232-3000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number40393
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: