Provider Demographics
NPI:1457388274
Name:FORMAN-BAILEY, KIRSTEN J (DC)
Entity Type:Individual
Prefix:
First Name:KIRSTEN
Middle Name:J
Last Name:FORMAN-BAILEY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:513 W UNION ST
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NY
Mailing Address - Zip Code:14513-1365
Mailing Address - Country:US
Mailing Address - Phone:315-331-1801
Mailing Address - Fax:315-331-1802
Practice Address - Street 1:513 W UNION ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NY
Practice Address - Zip Code:14513-1365
Practice Address - Country:US
Practice Address - Phone:315-331-1801
Practice Address - Fax:315-331-1802
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2010-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX008568-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY7653252OtherAETNA
NY106029ANOtherPREFERRED CARE
NY02264693Medicaid
NYP010008568OtherBLUE CROSS
NYRC70008568OtherPOMCO
NY14275BMedicare ID - Type Unspecified