Basic Information
Provider Information | |||||||||
NPI: | 1477768208 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FORTMAN | ||||||||
FirstName: | JAMES | ||||||||
MiddleName: | KENNETH | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: | II | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3200 BURNET AVE | ||||||||
Address2: | 3 SOUTH | ||||||||
City: | CINCINNATI | ||||||||
State: | OH | ||||||||
PostalCode: | 452293019 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5135855503 | ||||||||
FaxNumber: | 5135855511 | ||||||||
Practice Location | |||||||||
Address1: | 7759 UNIVERSITY DR | ||||||||
Address2: | SUITE C | ||||||||
City: | WEST CHESTER | ||||||||
State: | OH | ||||||||
PostalCode: | 450696578 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5134758262 | ||||||||
FaxNumber: | 5134758283 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/14/2007 | ||||||||
LastUpdateDate: | 12/27/2012 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 35-090947 | OH | N |   | Allopathic & Osteopathic Physicians | Anesthesiology |   | 207LP2900X | 35.090947 | OH | Y |   | Allopathic & Osteopathic Physicians | Anesthesiology | Pain Medicine |
ID Information
ID | Type | State | Issuer | Description | 3071938 | 05 | OH |   | MEDICAID | 1025384280001 | 05 | PA |   | MEDICAID | 000000312885 | 01 |   | UNISON | OTHER |