Provider Demographics
NPI:1215027461
Name:FORMAN, MERVYN B (MD)
Entity type:Individual
Prefix:MR
First Name:MERVYN
Middle Name:B
Last Name:FORMAN
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:975 JOHNSON FERRY RD NE
Mailing Address - Street 2:STE 340
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1619
Mailing Address - Country:US
Mailing Address - Phone:404-256-0121
Mailing Address - Fax:404-843-0355
Practice Address - Street 1:975 JOHNSON FERRY RD NE
Practice Address - Street 2:STE 340
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1619
Practice Address - Country:US
Practice Address - Phone:404-256-0121
Practice Address - Fax:404-843-0355
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2008-01-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
GA035873207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000526446DMedicaid
GAA96909Medicare UPIN
GA000526446DMedicaid