Healthcare Provider Details

I. General information

NPI: 1457452591
Provider Name (Legal Business Name): MARK ROUTON FORTSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 08/22/2022
Certification Date: 08/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 HAMILTON RD STE B
COLUMBUS GA
31904-8856
US

IV. Provider business mailing address

2200 HAMILTON RD STE B
COLUMBUS GA
31904-8856
US

V. Phone/Fax

Practice location:
  • Phone: 706-655-8800
  • Fax: 706-940-9767
Mailing address:
  • Phone: 706-655-8800
  • Fax: 706-940-9767

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number24937
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number024937
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: