Provider Demographics
NPI:1629568159
Name:FORTIS MEDICAL GROUP, LLC
Entity Type:Organization
Organization Name:FORTIS MEDICAL GROUP, LLC
Other - Org Name:FORTIS MEDICAL GROUP, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JAGMOHAN
Authorized Official - Middle Name:N
Authorized Official - Last Name:VIROJA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:407-286-1875
Mailing Address - Street 1:1803 PARK CENTER DR STE 103
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32835-6216
Mailing Address - Country:US
Mailing Address - Phone:407-286-1875
Mailing Address - Fax:407-386-8000
Practice Address - Street 1:1803 PARK CENTER DR STE 103
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32835-6216
Practice Address - Country:US
Practice Address - Phone:407-286-1875
Practice Address - Fax:407-386-8000
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-10
Last Update Date:2018-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME83974207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty