Healthcare Provider Details

I. General information

NPI: 1619119252
Provider Name (Legal Business Name): CHAD MICHAEL FORTUN M D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2009
Last Update Date: 01/14/2020
Certification Date: 01/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 MEDICAL CENTER DR
WILMINGTON NC
28401-7307
US

IV. Provider business mailing address

1717 SHIPYARD BLVD STE 350 CAROLINA SPORTS MEDICINE
WILMINGTON NC
28403
US

V. Phone/Fax

Practice location:
  • Phone: 910-341-3300
  • Fax: 910-251-2067
Mailing address:
  • Phone: 910-799-0110
  • Fax: 910-799-1958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number2015-01168
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number2015-01168
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: