MEDICARE: DR. EUGENE M FORTUNA D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	004017	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	05884020	OTHER	MO	BLUE CROSS BLUE SHILED

General Provider Information

NPI Number	:	1023098761
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. EUGENE M FORTUNA D.C.

Provider Business Mailing Address
First Line	:	7626 N OAK TRFY
Second Line	:
City	:	GLADSTONE
State	:	MO
Zip	:	64118-1751
Country	:	US
Telephone Number	:	816-468-5200
Fax Number	:	816-468-5201

Provider Business Practice Location Address
First Line	:	7626 N OAK TRFY
Second Line	:
City	:	GLADSTONE
State	:	MO
Zip	:	64118-1751
Country	:	US
Telephone Number	:	816-468-5200
Fax Number	:	816-468-5201

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2006
Last Update Date	:	08/02/2013

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