Form Physical Therapy, a Professional Corporation

Primary specialty

Physical Therapy Clinic/CenterTaxonomy code 261QP2000X

License

29589 Issued in CA

Legal business name

FORM PHYSICAL THERAPY, A PROFESSIONAL CORPORATION

Doing business as

Form Physical Therapy

Practice address

2358 Pine Street
San Francisco, CA 94115

Phone

(415) 297-4113

Fax

(415) 684-7694

NPI assigned

Aug 26, 2008

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mrs. Stacee Lee Brown, PT, DPT, ATCNPI 1861697922

Title

Owner/President

Phone

(415) 297-4113

Specialties & licenses 1

Addresses

Other names 1

• Form Physical Therapy Doing business as

Medicare fee-for-service enrollment

Enrolled in CA

Enrollment records 1

Locations

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

• Stacee Lee Brown, P.T., D.P.T, A.T.C

  • Physical Therapist
  • San Francisco, CA
  • NPI 1861697922
  Medicare reassignment Authorized official
• Maryalice Oshana Biondi, PT

  • Physical Therapist
  • Brewster, MA
  • NPI 1033127790
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1219708800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1346889600000",
    "number": "1174770630",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "68 DOMINICAN DRIVE",
            "city": "SAN RAFAEL",
            "state": "CA",
            "postal_code": "94901",
            "telephone_number": "415-297-4113",
            "fax_number": "415-684-7694"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2358 PINE STREET",
            "city": "SAN FRANCISCO",
            "state": "CA",
            "postal_code": "94115",
            "telephone_number": "415-297-4113",
            "fax_number": "415-684-7694"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "FORM PHYSICAL THERAPY, A PROFESSIONAL CORPORATION",
        "organizational_subpart": "NO",
        "enumeration_date": "2008-08-26",
        "last_updated": "2012-09-06",
        "status": "A",
        "authorized_official_last_name": "BROWN",
        "authorized_official_first_name": "STACEE",
        "authorized_official_middle_name": "LEE",
        "authorized_official_title_or_position": "OWNER/PRESIDENT",
        "authorized_official_telephone_number": "415-297-4113",
        "authorized_official_name_prefix": "Mrs.",
        "authorized_official_credential": "PT, DPT, ATC"
    },
    "taxonomies": [
        {
            "code": "261QP2000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center, Physical Therapy",
            "state": "CA",
            "license": "29589",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Form Physical Therapy",
            "code": "3",
            "type": "Doing Business As"
        }
    ]
}

• Steven A Foreman, MD
• Reni Forer, MD
• David Forero
• Romilda Foresti-Lorente, MD
• Natalya Forkin
• Holly Forman-Patel
• Therese Eileen Forman, MSW
• Samuel Formo
• Rochelle Forni
• Katherine Faye Forquer

• Physical Therapy Clinic/Center in San Francisco, CA
• Providers in San Francisco, CA by specialty
• Physical Therapy Clinic/Center in California

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Sep 6, 2012; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.