Healthcare Provider Details

I. General information

NPI: 1841284247
Provider Name (Legal Business Name): JOHN L FORTNEY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2005
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4439 STATE ROUTE 159 STE G10
CHILLICOTHEE OH
45601-8207
US

IV. Provider business mailing address

272 HOSPITAL RD SUITE 4
CHILLICOTHEE OH
45601-9031
US

V. Phone/Fax

Practice location:
  • Phone: 740-779-4300
  • Fax: 740-779-4390
Mailing address:
  • Phone: 740-779-8556
  • Fax: 740-779-7477

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number35046995
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: