Provider Demographics
NPI:1508923137
Name:MICHAEL A FORMAN PHD INC
Entity Type:Organization
Organization Name:MICHAEL A FORMAN PHD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:FORMAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:614-263-5908
Mailing Address - Street 1:3545 OLENTANGY RIVER RD
Mailing Address - Street 2:SUITE 214
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43214-3907
Mailing Address - Country:US
Mailing Address - Phone:614-263-5908
Mailing Address - Fax:614-263-5941
Practice Address - Street 1:3545 OLENTANGY RIVER ROAD
Practice Address - Street 2:SUITE 214
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43214-3907
Practice Address - Country:US
Practice Address - Phone:614-263-5908
Practice Address - Fax:614-263-5941
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-02
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2928103T00000X
OH4417103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH9311961Medicare PIN
DB6305Medicare PIN