MEDICARE: MT. ZION COMMUNITY REINVESTMENT CORPORATION

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1528899135
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MT. ZION COMMUNITY REINVESTMENT CORPORATION

Provider Business Mailing Address
First Line	:	802 N JEFFERSON ST
Second Line	:
City	:	ALBANY
State	:	GA
Zip	:	31701-2363
Country	:	US
Telephone Number	:	229-888-7420
Fax Number	:	229-888-7421

Provider Business Practice Location Address
First Line	:	802 N JEFFERSON ST
Second Line	:
City	:	ALBANY
State	:	GA
Zip	:	31701-2363
Country	:	US
Telephone Number	:	229-888-7420
Fax Number	:	229-888-7421

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	NEDRA S FORTSON
Credential	:	APRN
Telephone Number	:	770-330-8496

Provider Enumeration Date	:	08/13/2024
Last Update Date	:	08/13/2024

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