Provider Demographics
NPI:1871712174
Name:FOREST AVENUE MEDICAL GROUP
Entity type:Organization
Organization Name:FOREST AVENUE MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:J
Authorized Official - Last Name:MCGUIRE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:408-292-2552
Mailing Address - Street 1:2100 FOREST AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1422
Mailing Address - Country:US
Mailing Address - Phone:408-292-2552
Mailing Address - Fax:408-292-1943
Practice Address - Street 1:2100 FOREST AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1422
Practice Address - Country:US
Practice Address - Phone:408-292-2552
Practice Address - Fax:408-292-1943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA(MULTIPLE PROVIDERS)207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA181-2872-8OtherCA STATE EMPLOYER NUMBER
CAZZZ39570ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER