Healthcare Provider Details

I. General information

NPI: 1366426066
Provider Name (Legal Business Name): KENNETH C. FORTGANG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2005
Last Update Date: 06/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 BEL AIR DR
HIGHLAND BEACH FL
33487-4207
US

IV. Provider business mailing address

1125 BEL AIR DRIVE
HIGHLAND BEACH FL
33487
US

V. Phone/Fax

Practice location:
  • Phone: 561-756-4610
  • Fax: 561-274-6770
Mailing address:
  • Phone: 561-756-4610
  • Fax: 561-274-6770

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME43615
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: