Provider Demographics
NPI:1427298793
Name:FORTKAMP, MARY ELAINE (CST)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELAINE
Last Name:FORTKAMP
Suffix:
Gender:F
Credentials:CST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7584 ROSELAKE DR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-2251
Mailing Address - Country:US
Mailing Address - Phone:937-454-5247
Mailing Address - Fax:
Practice Address - Street 1:1520 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2698
Practice Address - Country:US
Practice Address - Phone:937-223-1279
Practice Address - Fax:937-223-9979
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-26
Last Update Date:2009-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH027735246ZS0410X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH068880307-12OtherMEDICARE