Healthcare Provider Details

I. General information

NPI: 1396854089
Provider Name (Legal Business Name): MISHKIN MILLER FORMAN PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

238-25 HILLSIDE AVE
BELLEROSE NY
11426-1329
US

IV. Provider business mailing address

238-25 HILLSIDE AVE
BELLEROSE NY
11426-1329
US

V. Phone/Fax

Practice location:
  • Phone: 718-464-7376
  • Fax: 718-464-0301
Mailing address:
  • Phone: 718-464-7376
  • Fax: 718-464-0301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number082626
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number072785
License Number StateNY

VIII. Authorized Official

Name: DR. PAUL J MILLER
Title or Position: DOCTOR
Credential: MD
Phone: 718-464-7376