Provider Demographics
NPI:1922256619
Name:FORMAN, IRWIN H
Entity Type:Individual
Prefix:DR
First Name:IRWIN
Middle Name:H
Last Name:FORMAN
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 1:80 SYCAMORE DR
Mailing Address - Street 2:APT, 202
Mailing Address - City:ELIZABETHTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:17022-3008
Mailing Address - Country:US
Mailing Address - Phone:717-569-1545
Mailing Address - Fax:
Practice Address - Street 1:80 SYCAMORE DR
Practice Address - Street 2:APT, 202
Practice Address - City:ELIZABETHTOWN
Practice Address - State:PA
Practice Address - Zip Code:17022-3008
Practice Address - Country:US
Practice Address - Phone:717-569-1545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD031868L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAB40679Medicare UPIN