Provider Demographics
NPI:1396730610
Name:FORTIER, RENA CHASE (MD)
Entity type:Individual
Prefix:DR
First Name:RENA
Middle Name:CHASE
Last Name:FORTIER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1051 LONG RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06903-4436
Mailing Address - Country:US
Mailing Address - Phone:203-329-7960
Mailing Address - Fax:203-329-7920
Practice Address - Street 1:1051 LONG RIDGE RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06903-4436
Practice Address - Country:US
Practice Address - Phone:203-329-7960
Practice Address - Fax:203-329-7920
Is Sole Proprietor?:No
Enumeration Date:2005-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT036076174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTB19776Medicare UPIN