MEDICARE: DR. GREGORY LAMAR FORTNER M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084A0401X	Addiction Medicine (Psychiatry & Neurology) Physician	032733	GA
2	207Q00000X	Family Medicine Physician	032733	GA

General Provider Information

NPI Number	:	1326240904
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY LAMAR FORTNER M.D.

Provider Business Mailing Address
First Line	:	222S MAIN ST
Second Line	:
City	:	REIDSVILLE
State	:	GA
Zip	:	30453-4602
Country	:	US
Telephone Number	:	912-394-1002
Fax Number	:

Provider Business Practice Location Address
First Line	:	222S MAIN ST
Second Line	:
City	:	REIDSVILLE
State	:	GA
Zip	:	30453-4602
Country	:	US
Telephone Number	:	912-394-1002
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/05/2007
Last Update Date	:	12/16/2015

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