Healthcare Provider Details

I. General information

NPI: 1043258213
Provider Name (Legal Business Name): MICHAEL EDWARD ORT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2006
Last Update Date: 10/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 BLACKMON ST
MEDINA TN
38355-8839
US

IV. Provider business mailing address

713 BLACKMON ST
MEDINA TN
38355-8839
US

V. Phone/Fax

Practice location:
  • Phone: 731-212-4495
  • Fax: 866-963-0164
Mailing address:
  • Phone: 731-212-4495
  • Fax: 866-963-0164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD26929
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMD26929
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberMD26929
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: