Healthcare Provider Details

I. General information

NPI: 1144390121
Provider Name (Legal Business Name): MARK R. FORTSON, M.D. P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1907 - C 7TH AVE
COLUMBUS GA
31901
US

IV. Provider business mailing address

1907 - C 7TH AVE
COLUMBUS GA
31901
US

V. Phone/Fax

Practice location:
  • Phone: 706-653-1072
  • Fax: 706-653-1075
Mailing address:
  • Phone: 706-653-1072
  • Fax: 706-653-1075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number024937
License Number StateGA

VIII. Authorized Official

Name: MARK R FORTSON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 706-653-1072