1144402983 NPI number — EVERETT FORMAN PC

Table of content: (NPI 1144402983)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144402983 NPI number — EVERETT FORMAN PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERETT FORMAN PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MEDI SCENE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1144402983
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
47 SWEET RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BALLSTON LAKE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12019-1805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-899-6657
Provider Business Mailing Address Fax Number:
518-899-0023

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
585 TROY SCHENECTADY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LATHAM
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12110-2811
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-785-6004
Provider Business Practice Location Address Fax Number:
518-785-1702
Provider Enumeration Date:
12/04/2007

Additional Information

Authorized Official

Authorized Official Last Name:
FORMAN
Authorized Official First Name:
EVERETT
Authorized Official Middle Name:
ROY
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
518-899-6657

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 01148 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000401336001 . This is a "BLUE SHJELD OF NENY" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 080031557 . This is a "MEDICARE RAILROAD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10000672 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 49E991 . This is a "EMPIRE BLUEXBLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".




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