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General NPI Number Information
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NPI Number | 1144207382
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Entity Type | Individual
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Provider Name | THOMAS O FORT PA
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Gender | Male
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Dates
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Enumeration Date | 12/29/2005
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Last Update Date | 06/16/2018
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Provider Practice Location Address
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Address Line | 701 S MORGAN AVE
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City | ANDREWS
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State | SC
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Zip | 29510-2959
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Country | US
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Telephone | 843-264-5253
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Fax | 843-264-5970
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Provider Business Mailing Address
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Address Line | PO BOX 1209
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City | MURRELLS INLET
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State | SC
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Zip | 29576-1209
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Country | US
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Telephone | 843-652-8220
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Fax | 843-527-7080
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | 780
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License Number State | SC
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