Provider Demographics
NPI:1578744314
Name:FORGIE, ROAN EMANUEL
Entity Type:Individual
Prefix:MR
First Name:ROAN
Middle Name:EMANUEL
Last Name:FORGIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:669 E 237TH ST
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10466-1409
Mailing Address - Country:US
Mailing Address - Phone:646-591-4970
Mailing Address - Fax:
Practice Address - Street 1:3065 DANIELS RD # 1077
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-7002
Practice Address - Country:US
Practice Address - Phone:646-591-4970
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-20
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY273030164W00000X
NYF403033363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02907775Medicaid