Provider Demographics
NPI:1487731287
Name:GREGORY J FORSTALL MD PC
Entity type:Organization
Organization Name:GREGORY J FORSTALL MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:J
Authorized Official - Last Name:FORSTALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:810-720-0639
Mailing Address - Street 1:PO BOX 321068
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48532-0019
Mailing Address - Country:US
Mailing Address - Phone:810-720-0639
Mailing Address - Fax:810-230-1978
Practice Address - Street 1:401 S BALLENGER HWY
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48532-3638
Practice Address - Country:US
Practice Address - Phone:810-720-0639
Practice Address - Fax:810-230-1978
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2016-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301061462207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
E63897Medicare UPIN
MI0P19890Medicare PIN