Healthcare Provider Details

I. General information

NPI: 1841254166
Provider Name (Legal Business Name): DR. SAMUEL L. FORT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203B MOCKSVILLE AVE
SALISBURY NC
28144-3325
US

IV. Provider business mailing address

PO BOX 2145 203 B MOCKSVILLE AVENUE
SALISBURY NC
28145-2145
US

V. Phone/Fax

Practice location:
  • Phone: 704-636-0971
  • Fax: 704-636-8854
Mailing address:
  • Phone: 704-636-0971
  • Fax: 704-636-8554

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number9501242
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: