Healthcare Provider Details

I. General information

NPI: 1215027461
Provider Name (Legal Business Name): MERVYN B. FORMAN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

755 MOUNT VERNON HWY NE STE 530
SANDY SPRINGS GA
30328-4287
US

IV. Provider business mailing address

755 MOUNT VERNON HWY NE STE 530
SANDY SPRINGS GA
30328-4287
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-7970
  • Fax: 404-250-0553
Mailing address:
  • Phone: 404-252-7970
  • Fax: 404-250-0553

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number035873
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: