1396789764 NPI number — JEAN-PIERRE FORAGE M.D.

Table of content: JEAN-PIERRE FORAGE M.D. (NPI 1396789764)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396789764 NPI number — JEAN-PIERRE FORAGE M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORAGE
Provider First Name:
JEAN-PIERRE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FORAGE
Provider Other First Name:
J.P.
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
M.D.
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1396789764
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/07/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11645 ANGUS RD
Provider Second Line Business Mailing Address:
SUITE B-6
Provider Business Mailing Address City Name:
AUSTIN
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78759-4020
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
512-443-5954
Provider Business Mailing Address Fax Number:
512-326-3433

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11645 ANGUS RD
Provider Second Line Business Practice Location Address:
STE B-6
Provider Business Practice Location Address City Name:
AUSTIN
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78759-4020
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
512-443-5954
Provider Business Practice Location Address Fax Number:
512-326-3433
Provider Enumeration Date:
06/16/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  G5050 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 80T081 . This is a "BCBS INDIVIDUAL #" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 113863802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 083183601 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 742638492 . This is a "TAX ID" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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