Provider Demographics
NPI:1336211549
Name:FORTMAN, CARRIE S (PAC)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:S
Last Name:FORTMAN
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 N RANDALL RD
Mailing Address - Street 2:
Mailing Address - City:ELGIN
Mailing Address - State:IL
Mailing Address - Zip Code:60123-7803
Mailing Address - Country:US
Mailing Address - Phone:847-214-5100
Mailing Address - Fax:847-289-5579
Practice Address - Street 1:1600 N RANDALL RD
Practice Address - Street 2:
Practice Address - City:ELGIN
Practice Address - State:IL
Practice Address - Zip Code:60123
Practice Address - Country:US
Practice Address - Phone:847-214-5100
Practice Address - Fax:847-289-5579
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085001080363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL206147OtherMEDICARE GROUP PTAN
ILF400138108OtherMEDICARE INDIVIDUAL PTAN
IL554850Medicare ID - Type Unspecified
S28817Medicare UPIN