Healthcare Provider Details

I. General information

NPI: 1972342046
Provider Name (Legal Business Name): FORT HEALTH MEDICAL GROUP PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2024
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S 2ND ST STE 404
SPRINGFIELD IL
62704-2542
US

IV. Provider business mailing address

613 WASHINGTON BLVD # 1297
JERSEY CITY NJ
07310-2900
US

V. Phone/Fax

Practice location:
  • Phone: 201-208-2616
  • Fax: 973-381-5773
Mailing address:
  • Phone: 201-208-2616
  • Fax: 973-381-5773

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNULL
# 4
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number StateNULL
# 5
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: TRACI CROSBY
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 201-503-4815