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General NPI Number Information
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NPI Number | 1215975289
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Entity Type | Organization
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Legal Business Name | FOREST MEDICAL GROUP, PLLC
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Dates
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Enumeration Date | 06/03/2006
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Last Update Date | 11/05/2007
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Provider Practice Location Address
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Address Line | 1360 N FOREST RD SUITE 3
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City | WILLIAMSVILLE
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State | NY
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Zip | 14221-1200
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Country | US
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Telephone | 716-689-4800
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Fax | 716-689-4816
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Provider Business Mailing Address
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Address Line | 1360 N FOREST RD SUITE 3
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City | WILLIAMSVILLE
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State | NY
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Zip | 14221-1200
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Country | US
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Telephone | 716-689-4800
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Fax | 716-689-4816
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Authorized Official
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Title or Position | PHYSICIAN , OWNER
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Name | RICHARD F DIVENCENZO
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Credential | M.D.
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Telephone | 716-689-4800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 188929-1
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License Number State | NY
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