1174508436 NPI number — VINCENT P. FORTUNATO MD

Table of content: VINCENT P. FORTUNATO MD (NPI 1174508436)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174508436 NPI number — VINCENT P. FORTUNATO MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORTUNATO
Provider First Name:
VINCENT
Provider Middle Name:
P.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174508436
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/28/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10004 KENNERLY RD
Provider Second Line Business Mailing Address:
SUITE #255A
Provider Business Mailing Address City Name:
SAINT LOUIS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63128-2141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-843-5140
Provider Business Mailing Address Fax Number:
314-843-8010

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2325 DOUGHERTY FERRY RD STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT LOUIS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63122-3356
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
148-216-8893
Provider Business Practice Location Address Fax Number:
314-821-1887
Provider Enumeration Date:
12/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207R00000X , with the licence number:  R1J64 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 110080662 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 206760100 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 431650657 . This is a "CIGNA HEALTHCARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 21532 . This is a "BLUE CROSS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 9499441 . This is a "UNITED HEALTHCARE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 173933 . This is a "HEALTHLINK" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 4084340 . This is a "AETNA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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