MEDICARE: JAMES D FORTENBERRY MD

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	207R00000X	Internal Medicine Physician	01041534A	IN
2	208000000X	Pediatrics Physician	01057726	IN

Other Identifiers

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

General Provider Information

NPI Number	:	1669439055
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMES D FORTENBERRY MD

Provider Business Mailing Address
First Line	:	8910 PURDUE RD
Second Line	:	STE.500
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-6100
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	6940 MICHIGAN RD
Second Line	:
City	:	INDIANAPOLIS
State	:	IN
Zip	:	46268-2800
Country	:	US
Telephone Number	:	317-266-2901
Fax Number	:	317-266-2916

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

Provider Enumeration Date	:	04/28/2006
Last Update Date	:	04/01/2011

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