Provider Demographics
NPI:1235597741
Name:TABITHA B. FORTT, M.D., LLC
Entity Type:Organization
Organization Name:TABITHA B. FORTT, M.D., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:TABITHA
Authorized Official - Middle Name:B
Authorized Official - Last Name:FORTT
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:203-674-0774
Mailing Address - Street 1:37 GLENBROOK RD
Mailing Address - Street 2:SUITE #3
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-2913
Mailing Address - Country:US
Mailing Address - Phone:203-674-0774
Mailing Address - Fax:203-674-0766
Practice Address - Street 1:37 GLENBROOK RD
Practice Address - Street 2:SUITE #3
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-2913
Practice Address - Country:US
Practice Address - Phone:203-674-0774
Practice Address - Fax:203-674-0766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-29
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037894261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008036735Medicaid
CTH41669Medicare UPIN
CT008036735Medicaid