Provider Demographics
NPI:1144402983
Name:EVERETT FORMAN PC
Entity Type:Organization
Organization Name:EVERETT FORMAN PC
Other - Org Name:MEDI SCENE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EVERETT
Authorized Official - Middle Name:ROY
Authorized Official - Last Name:FORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:518-899-6657
Mailing Address - Street 1:47 SWEET RD
Mailing Address - Street 2:
Mailing Address - City:BALLSTON LAKE
Mailing Address - State:NY
Mailing Address - Zip Code:12019-1805
Mailing Address - Country:US
Mailing Address - Phone:518-899-6657
Mailing Address - Fax:518-899-0023
Practice Address - Street 1:585 TROY SCHENECTADY RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-2811
Practice Address - Country:US
Practice Address - Phone:518-785-6004
Practice Address - Fax:518-785-1702
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-04
Last Update Date:2007-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01148OtherMVP
NY000401336001OtherBLUE SHJELD OF NENY
NY080031557OtherMEDICARE RAILROAD
NY10000672OtherCDPHP
NY49E991OtherEMPIRE BLUEXBLUE SHIELD
NY49E991OtherEMPIRE BLUEXBLUE SHIELD
NY01148OtherMVP