Basic Information
| Provider Information | |||||||||
| NPI: | 1609847706 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORMAN | ||||||||
| FirstName: | KIM | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4494 N PALMER RD | ||||||||
| Address2: | WALTER REED NATIONAL MILITARY MEDICAL CENTER | ||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208890001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012954810 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4494 N PALMER RD | ||||||||
| Address2: | WALTER REED NATIONAL MILITARY MEDICAL CENTER | ||||||||
| City: | BETHESDA | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208890001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3012954810 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2006 | ||||||||
| LastUpdateDate: | 02/03/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | ME69319 | FL | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | 200301354 | NC | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.