Healthcare Provider Details

I. General information

NPI: 1609847706
Provider Name (Legal Business Name): KIM M FORMAN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2006
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4494 N PALMER RD WALTER REED NATIONAL MILITARY MEDICAL CENTER
BETHESDA MD
20889-0001
US

IV. Provider business mailing address

4494 N PALMER RD WALTER REED NATIONAL MILITARY MEDICAL CENTER
BETHESDA MD
20889-0001
US

V. Phone/Fax

Practice location:
  • Phone: 301-295-4810
  • Fax:
Mailing address:
  • Phone: 301-295-4810
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberME69319
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number200301354
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: