Provider Demographics
NPI:1659567071
Name:FLORENDA L. FORTNER, M.D., LLC
Entity Type:Organization
Organization Name:FLORENDA L. FORTNER, M.D., LLC
Other - Org Name:INTERNAL MEDICINE & CLINICAL ANTI-AGING CENTER LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:M.D.
Authorized Official - Prefix:
Authorized Official - First Name:FLORENDA
Authorized Official - Middle Name:L
Authorized Official - Last Name:FORTNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:727-841-0700
Mailing Address - Street 1:5535 GRAND BLVD
Mailing Address - Street 2:SUITE C
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652
Mailing Address - Country:US
Mailing Address - Phone:727-841-0700
Mailing Address - Fax:727-841-6969
Practice Address - Street 1:5535 GRAND BLVD
Practice Address - Street 2:SUITE C
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652
Practice Address - Country:US
Practice Address - Phone:727-841-0700
Practice Address - Fax:727-841-6969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-19
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME86987207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK6475Medicare PIN