Individual
CARRIE S FORTMAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PAC
Contact information
Practice address
1600 N RANDALL RD, ELGIN, IL 60123
(847) 214-5100
(847) 289-5579
Mailing address
1600 N RANDALL RD, ELGIN, IL 60123-7803
(847) 214-5100
(847) 289-5579
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
085001080
IL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
206147
MEDICARE GROUP PTAN
IL
01
—
F400138108
MEDICARE INDIVIDUAL PTAN
IL
Enumeration date
11/14/2006
Last updated
03/11/2020
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