Basic Information
| Provider Information | |||||||||
| NPI: | 1386618692 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORTIN | ||||||||
| FirstName: | AUGUSTE | ||||||||
| MiddleName: | H | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | VI | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1450 CHAPEL ST | ||||||||
| Address2: | ADULT PRIMARY CARE CENTER | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065114405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037894094 | ||||||||
| FaxNumber: | 2037893007 | ||||||||
| Practice Location | |||||||||
| Address1: | 1450 CHAPEL ST | ||||||||
| Address2: | ADULT PRIMARY CARE CENTER | ||||||||
| City: | NEW HAVEN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 065114405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2037894044 | ||||||||
| FaxNumber: | 2037893007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/14/2006 | ||||||||
| LastUpdateDate: | 05/18/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 034714 | CT | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 001347146 | 05 | CT | MEDICAID |