# FORT HEALTH MEDICAL GROUP PA

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- **Entity:** Organization
- **Status:** Active
- **Other names:** Fort Health Medical Group of IL
- **Organization subpart:** No

## Provider details

- **NPI number:** 1972342046
- **Authorized official:** TRACI CROSBY (CREDENTIALING MANAGER)
- **Authorized official phone:** (201) 503-4815

## Contact information

- **Practice address:** 600 S 2ND ST STE 404, SPRINGFIELD, IL 62704-2542
- **Practice address phone:** (201) 208-2616
- **Practice address fax:** (973) 381-5773
- **Mailing address:** 613 WASHINGTON BLVD \# 1297, JERSEY CITY, NJ 07310-2900
- **Mailing address phone:** (201) 208-2616
- **Mailing address fax:** (973) 381-5773

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 101YP2500X | Professional Counselor | — | NULL | — |
| 101YP2500X | Professional Counselor | — | — | — |
| 103TC2200X | Clinical Child & Adolescent Psychologist | — | NULL | — |
| 103TC2200X | Clinical Child & Adolescent Psychologist | — | — | — |
| 1041C0700X | Clinical Social Worker | — | NULL | — |
| 1041C0700X | Clinical Social Worker | — | — | — |
| 2084P0804X | Child & Adolescent Psychiatry Physician | — | NULL | Yes |
| 2084P0804X | Child & Adolescent Psychiatry Physician | — | — | Yes |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | NULL | — |
| 363LP0808X | Psychiatric/Mental Health Nurse Practitioner | — | — | — |

## Other

- **Enumeration date:** 05/20/2024
- **Last updated:** 03/26/2025