Healthcare Provider Details

I. General information

NPI: 1275507113
Provider Name (Legal Business Name): SAMUEL FITZROY CORT JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 06/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

289 JONESBORO RD STE 339
MCDONOUGH GA
30253-3725
US

IV. Provider business mailing address

289 JONESBORO RD STE 339
MCDONOUGH GA
30253-3725
US

V. Phone/Fax

Practice location:
  • Phone: 770-656-6639
  • Fax: 770-783-2042
Mailing address:
  • Phone: 770-656-6639
  • Fax: 770-783-2042

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085B0100X
TaxonomyBody Imaging Physician
License NumberME82592
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License NumberME82592
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberME82592
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License NumberME82592
License Number StateFL
# 5
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberME82592
License Number StateFL
# 6
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number35.076831
License Number StateOH
# 7
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number26608
License Number StateSC
# 8
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number054262
License Number StateGA
# 9
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number4301083098
License Number StateMI
# 10
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number120443
License Number StateNC
# 11
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberME82592
License Number StateFL
# 12
Primary TaxonomyN
Taxonomy Code2085U0001X
TaxonomyDiagnostic Ultrasound Physician
License NumberME82592
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: