MEDICARE: JOSEPH D FORTIN D.O.

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	208100000X	Physical Medicine & Rehabilitation Physician	02001553A	IN
2	208VP0014X	Interventional Pain Medicine Physician	02001553A	IN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	250008768	OTHER	IN	RR MEDICARE

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	:	1841292612
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH D FORTIN D.O.

Provider Business Mailing Address
First Line	:	9502 LIMA ROAD
Second Line	:	SUITE 103
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-9270
Country	:	US
Telephone Number	:	260-459-7313
Fax Number	:	260-436-0628

Provider Business Practice Location Address
First Line	:	9502 LIMA ROAD
Second Line	:	STE 103
City	:	FORT WAYNE
State	:	IN
Zip	:	46818-9270
Country	:	US
Telephone Number	:	260-459-7313
Fax Number	:	260-436-0628

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

Provider Enumeration Date	:	08/11/2005
Last Update Date	:	10/18/2017

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Directions to “ JOSEPH D FORTIN D.O.” Practice Location

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