Provider Demographics
NPI:1487779567
Name:FORTMAN, CHRISTOPHER JOSEPH (MPT)
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:JOSEPH
Last Name:FORTMAN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3477 S DIXIE HWY
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45804-3755
Mailing Address - Country:US
Mailing Address - Phone:419-331-2161
Mailing Address - Fax:419-227-7767
Practice Address - Street 1:3477 S DIXIE HWY
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45804-3755
Practice Address - Country:US
Practice Address - Phone:419-331-2161
Practice Address - Fax:419-227-7767
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2008-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH08532225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2619143Medicaid
OH000000365466OtherANTHEM PIN NUMBER
OH0812438OtherCIGNA PT NUMBER
OH000000365466OtherANTHEM PIN NUMBER