Healthcare Provider Details

I. General information

NPI: 1689721573
Provider Name (Legal Business Name): ILANA S. FORTGANG M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2007
Last Update Date: 06/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 MEDICAL CENTER BLVD. SUITE S-450
MARRERO LA
70072
US

IV. Provider business mailing address

P.O. BOX 1520
MARRERO LA
70073-1520
US

V. Phone/Fax

Practice location:
  • Phone: 504-349-6401
  • Fax: 504-349-6444
Mailing address:
  • Phone: 504-349-6423
  • Fax: 504-934-8097

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number023358
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License NumberMD.023358
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: