Basic Information
| Provider Information | |||||||||
| NPI: | 1063497543 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FOREBACK | ||||||||
| FirstName: | JAMI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1397 S LINDEN RD | ||||||||
| Address2: | STE A | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485324194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107209300 | ||||||||
| FaxNumber: | 8107209304 | ||||||||
| Practice Location | |||||||||
| Address1: | 1397 S LINDEN RD | ||||||||
| Address2: | STE A | ||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485324194 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8107209300 | ||||||||
| FaxNumber: | 8107209304 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2005 | ||||||||
| LastUpdateDate: | 05/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 4301074046 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 14605 | 01 | MI | MCARE | OTHER | 0994378 | 01 | MI | HEALTH PLUS | OTHER | 1102506552 | 01 | MI | BLUE CROSS | OTHER | H76499 | 01 | MI | HAP | OTHER | 1007004 | 01 | MI | MCLAREN HEALTH PLAN | OTHER | 110B56125 | 01 | MI | COMMUNITY BLUE PPO | OTHER | 1007004 | 01 | MI | HEALTH ADVANTAGE NETWORK | OTHER | 7513402 | 01 | MI | AETNA | OTHER | 110B56125 | 01 | MI | BLUE CHOICE | OTHER | 110B56125 | 01 | MI | BLUE CARE NETWORK | OTHER | 4458421 | 05 | MI | MEDICAID | 0994378 | 01 | MI | GENESEE HEALTH PLAN | OTHER | 110B56125 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | H76499 | 01 | MI | HEALTH NET FEDERAL SERVIC | OTHER |