Provider Demographics
NPI:1992734578
Name:FORUM MEDICAL CLINIC, PC
Entity type:Organization
Organization Name:FORUM MEDICAL CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:MARSHEH
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:586-580-0280
Mailing Address - Street 1:43184 DEQUINDRE RD STE 202
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48314-1709
Mailing Address - Country:US
Mailing Address - Phone:586-580-0280
Mailing Address - Fax:586-580-0281
Practice Address - Street 1:43184 DEQUINDRE RD STE 202
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48314-1709
Practice Address - Country:US
Practice Address - Phone:586-580-0280
Practice Address - Fax:586-580-0281
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MINM 069838207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E00984OtherBCBS
MI1106348002OtherBCBSM
MI4732824Medicaid
MI4732824Medicaid
MI4732824Medicaid
MI1106348002OtherBCBSM