Provider Demographics
NPI:1568460574
Name:FORTMAN, ROBERT (RN)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:FORTMAN
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 632572
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-2572
Mailing Address - Country:US
Mailing Address - Phone:513-891-0022
Mailing Address - Fax:
Practice Address - Street 1:1241 SHAWHAN RD
Practice Address - Street 2:
Practice Address - City:MORROW
Practice Address - State:OH
Practice Address - Zip Code:45152-9695
Practice Address - Country:US
Practice Address - Phone:513-865-5204
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-13
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH223641163W00000X
OH072814367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000553250OtherANTHEM
IN2001032200Medicaid
KY74009903Medicaid
OH2544769Medicaid
KY617574OtherWELLCARE
OH2544769Medicaid
OHFO8234791Medicare ID - Type Unspecified
000000553250OtherANTHEM