Healthcare Provider Details

I. General information

NPI: 1376419879
Provider Name (Legal Business Name): FORTRESS CLINICAL RESEARCH INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2025
Last Update Date: 07/17/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14501 LEMOYNE BLVD
BILOXI MS
39532-9326
US

IV. Provider business mailing address

14501 LEMOYNE BLVD
BILOXI MS
39532-9326
US

V. Phone/Fax

Practice location:
  • Phone: 601-316-5538
  • Fax:
Mailing address:
  • Phone: 601-316-5538
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MR. DEMARIO WILSON
Title or Position: CEO/ MEDICAL DIRECTOR
Credential:
Phone: 601-316-4613