Healthcare Provider Details

I. General information

NPI: 1669477592
Provider Name (Legal Business Name): JEREMY S FORSTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2005
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2321 STOUT RD
MENOMONIE WI
54751-7003
US

IV. Provider business mailing address

PO BOX 1510
EAU CLAIRE WI
54702-1510
US

V. Phone/Fax

Practice location:
  • Phone: 715-235-9671
  • Fax:
Mailing address:
  • Phone: 715-838-3635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number46700
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: