Provider Demographics
NPI:1104853332
Name:FORTIER, RICHARD E JR
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:E
Last Name:FORTIER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 PINELAND DR
Mailing Address - Street 2:
Mailing Address - City:NEW GLOUCESTER
Mailing Address - State:ME
Mailing Address - Zip Code:04260-5124
Mailing Address - Country:US
Mailing Address - Phone:207-688-8700
Mailing Address - Fax:207-688-8701
Practice Address - Street 1:60 PINELAND DR
Practice Address - Street 2:
Practice Address - City:NEW GLOUCESTER
Practice Address - State:ME
Practice Address - Zip Code:04260-5124
Practice Address - Country:US
Practice Address - Phone:207-688-8700
Practice Address - Fax:207-688-8701
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-26
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME80002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME002189OtherSTAR NUMBER
ME203580000Medicaid
D79223Medicare UPIN
ME047635Medicare ID - Type Unspecified