Provider Demographics
NPI:1104939578
Name:FORTINO, ROBERT D (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:D
Last Name:FORTINO
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1913 S BROAD ST
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-2216
Mailing Address - Country:US
Mailing Address - Phone:215-336-8000
Mailing Address - Fax:
Practice Address - Street 1:1913 S BROAD ST
Practice Address - Street 2:1ST FLOOR
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-2216
Practice Address - Country:US
Practice Address - Phone:215-336-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-17
Last Update Date:2008-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS009599L207R00000X
DEC2-0005782207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0017299880001Medicaid
NJ0017299880001Medicaid
NJG86446Medicare UPIN
DE003576I23Medicare PIN