Basic Information
| Provider Information | |||||||||
| NPI: | 1639101777 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORMAN | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | DIANNE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 79-01 BROADWAY | ||||||||
| Address2: | H-116 | ||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113731329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183343044 | ||||||||
| FaxNumber: | 7183345759 | ||||||||
| Practice Location | |||||||||
| Address1: | 7901 BROADWAY | ||||||||
| Address2: | ELMHURST HOSPITAL, ROOM H-116 | ||||||||
| City: | ELMHURST | ||||||||
| State: | NY | ||||||||
| PostalCode: | 113731329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7183343044 | ||||||||
| FaxNumber: | 7183345759 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2006 | ||||||||
| LastUpdateDate: | 10/27/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 211282 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics | 2080P0204X | 211282 | NY | N | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Emergency Medicine |
No ID Information.