Provider Demographics
NPI:1073227179
Name:FORMA MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:FORMA MEDICAL GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANUP
Authorized Official - Middle Name:
Authorized Official - Last Name:TILAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:319-594-4108
Mailing Address - Street 1:570 S EDMONDS LN STE 106
Mailing Address - Street 2:
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75067-3542
Mailing Address - Country:US
Mailing Address - Phone:319-594-4108
Mailing Address - Fax:
Practice Address - Street 1:570 S EDMONDS LN STE 106
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75067-3542
Practice Address - Country:US
Practice Address - Phone:319-594-4108
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-12
Last Update Date:2023-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory