=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548246523
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FORREST T. BATES MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/21/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 CEAPE AVE STE 13
-----------------------------------------------------
City | OSHKOSH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54901-5227
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-236-3251
-----------------------------------------------------
Fax | 920-236-3255
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 325 N COMMERCIAL ST
-----------------------------------------------------
City | NEENAH
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 54956-2665
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-722-1583
-----------------------------------------------------
Fax | 920-722-7454
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 25197
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------