=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437520509
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY JOSEEPH FORNESS MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/14/2015
-----------------------------------------------------
Last Update Date | 10/14/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3802 DOGWOOD AVE
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33410-4755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-386-9211
-----------------------------------------------------
Fax | 561-622-7694
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3802 DOGWOOD AVE
-----------------------------------------------------
City | PALM BEACH GARDENS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33410-4755
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 561-386-9211
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207XS0114X
-----------------------------------------------------
Taxonomy Name | Adult Reconstructive Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | ME71975
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------