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General NPI Number Information
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NPI Number | 1639365158
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Entity Type | Organization
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Legal Business Name | MICHAEL W FORMISANO MD PA
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Dates
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Enumeration Date | 09/18/2007
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Last Update Date | 11/15/2007
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Provider Practice Location Address
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Address Line | 4024 N CIRCLE DR
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City | HOLLYWOOD
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State | FL
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Zip | 33021-6726
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Country | US
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Telephone | 954-989-4110
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Fax | 954-989-7855
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Provider Business Mailing Address
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Address Line | 3939 HOLLYWOOD BLVD SUITE 2B
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City | HOLLYWOOD
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State | FL
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Zip | 33021-6749
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Country | US
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Telephone | 954-989-4110
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Fax | 954-989-7855
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. MICHAEL W FORMISANO
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Credential | MD PA
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Telephone | 954-989-4110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | ME 91614
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License Number State | FL
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