Healthcare Provider Details

I. General information

NPI: 1235119181
Provider Name (Legal Business Name): FOREST FAMILY PRACTICE CLINIC PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 10/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 MEDICAL LN
FOREST MS
39074-4039
US

IV. Provider business mailing address

PO BOX 600
FOREST MS
39074-0600
US

V. Phone/Fax

Practice location:
  • Phone: 601-469-4861
  • Fax: 601-469-4828
Mailing address:
  • Phone: 601-469-4861
  • Fax: 601-469-4828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number05638
License Number StateMS

VIII. Authorized Official

Name: JOHN PAUL LEE
Title or Position: PRESIDENT
Credential: M.D.
Phone: 601-469-4861