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General NPI Number Information
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NPI Number | 1366426066
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Entity Type | Individual
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Provider Name | KENNETH C. FORTGANG M.D.
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Gender | Male
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Dates
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Enumeration Date | 12/06/2005
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Last Update Date | 06/03/2010
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Provider Practice Location Address
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Address Line | 1125 BEL AIR DR
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City | HIGHLAND BEACH
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State | FL
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Zip | 33487-4207
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Country | US
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Telephone | 561-756-4610
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Fax | 561-274-6770
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Provider Business Mailing Address
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Address Line | 1125 BEL AIR DRIVE
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City | HIGHLAND BEACH
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State | FL
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Zip | 33487
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Country | US
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Telephone | 561-756-4610
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Fax | 561-274-6770
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number | ME43615
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License Number State | FL
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