Organization
EVERETT FORMAN PC
Active
Other names
Medi Scene
Organization subpart
No
Provider details
NPI number
Authorized official
DR. EVERETT ROY FORMAN M.D. (PRESIDENT)
(518) 899-6657
Entity
Organization
Contact information
Practice address
585 TROY SCHENECTADY RD, LATHAM, NY 12110-2811
(518) 785-6004
(518) 785-1702
Mailing address
47 SWEET RD, BALLSTON LAKE, NY 12019-1805
(518) 899-6657
(518) 899-0023
Taxonomy
Speciality
Code
Description
License number
State
208D00000X
General Practice Physician
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000401336001
BLUE SHJELD OF NENY
NY
01
—
01148
MVP
NY
01
—
080031557
MEDICARE RAILROAD
NY
01
—
10000672
CDPHP
NY
01
—
49E991
EMPIRE BLUEXBLUE SHIELD
NY
Enumeration date
12/04/2007
Last updated
12/19/2007
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