Healthcare Provider Details

I. General information

NPI: 1598766776
Provider Name (Legal Business Name): SANDRA L. FOREM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 E 41ST ST
NEW YORK NY
10017-6739
US

IV. Provider business mailing address

222 E 41ST ST
NEW YORK NY
10017-6739
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-7744
  • Fax: 212-263-7721
Mailing address:
  • Phone: 212-263-7744
  • Fax: 212-263-7721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number142499
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: