Individual
KENNETH GERALD FORTRESS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
520 S 7TH ST, VINCENNES, IN 47591-1038
(812) 882-5220
Mailing address
PO BOX 5628, LAFAYETTE, IN 47903-5628
(765) 448-4319
(765) 448-2921
Taxonomy
Speciality
Code
Description
License number
State
207ZP0102X
Anatomic Pathology & Clinical Pathology Physician
Primary
01032775A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000000082508
ANTHEM
IN
05
—
100259680A
—
IN
01
—
111890C
MEDICARE
IN
01
—
176600A
MEDICARE
IN
01
—
CA8380
RAIL ROAD MEDICARE
IN
01
—
CB5232
RAIL ROAD MEDICARE
IN
Enumeration date
06/27/2005
Last updated
04/26/2022
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