MEDICARE: EVERETT ROY FORMAN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	103928-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	10000672	OTHER	CDPHP
2	01148	OTHER	MVP
3	000401336001	OTHER	BLUE SHIELD OF NENY
4	49E991	OTHER	EMPIRE BCBS

General Provider Information

NPI Number	:	1528061967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVERETT ROY FORMAN M.D.

Provider Business Mailing Address
First Line	:	47 SWEET RD
Second Line	:
City	:	BALLSTON LAKE
State	:	NY
Zip	:	12019-1805
Country	:	US
Telephone Number	:	518-785-6004
Fax Number	:	518-785-1702

Provider Business Practice Location Address
First Line	:	585 TROY SCHENECTADY RD
Second Line	:
City	:	LATHAM
State	:	NY
Zip	:	12110-2811
Country	:	US
Telephone Number	:	518-785-6004
Fax Number	:	518-785-1702

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	07/08/2007

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Directions to “ EVERETT ROY FORMAN M.D.” Practice Location

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