MEDICARE: DR. KENNETH C. FORTGANG M.D.

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	2085R0202X	Diagnostic Radiology Physician	ME43615	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	300033744	OTHER	FL	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1366426066
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KENNETH C. FORTGANG M.D.

Provider Business Mailing Address
First Line	:	1125 BEL AIR DRIVE
Second Line	:
City	:	HIGHLAND BEACH
State	:	FL
Zip	:	33487
Country	:	US
Telephone Number	:	561-756-4610
Fax Number	:	561-274-6770

Provider Business Practice Location Address
First Line	:	1125 BEL AIR DR
Second Line	:
City	:	HIGHLAND BEACH
State	:	FL
Zip	:	33487-4207
Country	:	US
Telephone Number	:	561-756-4610
Fax Number	:	561-274-6770

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

Provider Enumeration Date	:	12/06/2005
Last Update Date	:	06/03/2010

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