Healthcare Provider Details

I. General information

NPI: 1427585579
Provider Name (Legal Business Name): MICHAEL FORTNEY CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2017
Last Update Date: 04/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 JOHNSON ST
HOLLYWOOD FL
33021-5421
US

IV. Provider business mailing address

117 NE 2ND AVE
DANIA BEACH FL
33004-4808
US

V. Phone/Fax

Practice location:
  • Phone: 954-265-2000
  • Fax:
Mailing address:
  • Phone: 954-655-8753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberARNP9269187
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN9269187
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: