=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285821314
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UPPER MISSISSIPPI SURGICAL ASSOCIATES PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/02/2007
-----------------------------------------------------
Last Update Date | 10/26/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9264 HIGHWAY 115
-----------------------------------------------------
City | RANDALL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56475-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-749-2607
-----------------------------------------------------
Fax | 320-749-8301
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9264 HIGHWAY 115
-----------------------------------------------------
City | RANDALL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56475-2501
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 320-749-2607
-----------------------------------------------------
Fax | 320-749-8301
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT/OWNER
-----------------------------------------------------
Name | DR. GEORGE M.A. FORTIER IV
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 320-749-2607
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 34195
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------