Provider Demographics
NPI:1083755920
Name:FORME MEDICAL CENTER, INC.
Entity Type:Organization
Organization Name:FORME MEDICAL CENTER, INC.
Other - Org Name:FORME URGENT CARE AND WELLNESS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAPPELLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:914-723-4900
Mailing Address - Street 1:7-11 SOUTH BROADWAY
Mailing Address - Street 2:SUITE 100
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10601-3055
Mailing Address - Country:US
Mailing Address - Phone:914-723-4900
Mailing Address - Fax:914-902-9011
Practice Address - Street 1:7-11 S BROADWAY
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-3531
Practice Address - Country:US
Practice Address - Phone:914-723-4900
Practice Address - Fax:914-448-5275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2020-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5947200R261Q00000X, 261QR0400X, 284300000X, 261QP2300X, 261QP3300X, 261QR0200X, 261QU0200X, 284300000X
NY5559500001332B00000X, 332BC3200X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes284300000XHospitalsSpecial Hospital
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02087823Medicaid
NY131056POtherHIP HEALTHPLAN PROVIDER
NYA2204263OtherOXFORD PROVIDER
NY5C7019OtherHEALTH NET PROVIDER
NY23901OtherCIGNA
NY5C7019OtherHEALTH NET PROVIDER
NY02087823Medicaid
NY=========OtherAETNA PROVIDER
NY=========OtherPOMCO PROVIDER
NY=========OtherAETNA PROVIDER
NY=========OtherAFFINITY HEALTH PROVIDER