Provider Demographics
NPI:1023012077
Name:FORTIER, MARTIN G (MD)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:G
Last Name:FORTIER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:199 S ADDISON RD
Mailing Address - Street 2:STE 105-106
Mailing Address - City:WOOD DALE
Mailing Address - State:IL
Mailing Address - Zip Code:60191-1534
Mailing Address - Country:US
Mailing Address - Phone:630-766-1552
Mailing Address - Fax:630-766-4220
Practice Address - Street 1:199 S ADDISON RD
Practice Address - Street 2:STE 105-106
Practice Address - City:WOOD DALE
Practice Address - State:IL
Practice Address - Zip Code:60191-1534
Practice Address - Country:US
Practice Address - Phone:630-766-1552
Practice Address - Fax:630-766-4220
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036062647207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL02222753OtherBCBS
K39876Medicare PIN
K39877Medicare PIN
ILC43740Medicare UPIN
ILK04976Medicare ID - Type Unspecified