Healthcare Provider Details

I. General information

NPI: 1518067636
Provider Name (Legal Business Name): MADELEINE FORTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 01/13/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 GLENLAKE PKWY
ATLANTA GA
30328-3473
US

IV. Provider business mailing address

3495 PIEDMONT RD NE BUILDING NINE
ATLANTA GA
30305-1717
US

V. Phone/Fax

Practice location:
  • Phone: 770-677-6085
  • Fax:
Mailing address:
  • Phone: 404-364-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number55433
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: