Individual
MARY ELAINE FORTKAMP
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
CST
Contact information
Practice address
1520 S MAIN ST, DAYTON, OH 45409-2698
(937) 223-1279
(937) 223-9979
Mailing address
7584 ROSELAKE DR, DAYTON, OH 45414-2251
(937) 454-5247
Taxonomy
Speciality
Code
Description
License number
State
246ZS0410X
Surgical Technologist
Primary
027735
OH
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
068880307-12
MEDICARE
OH
Enumeration date
02/26/2009
Last updated
02/26/2009
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