MEDICARE: MOLLY FORTNER MD

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	207R00000X	Internal Medicine Physician	2006-00046	NC

General Provider Information

NPI Number	:	1609946870
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MOLLY FORTNER MD

Provider Business Mailing Address
First Line	:	PO BOX 19305
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28219-9305
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	200 S COLLEGE ST
Second Line	:	STE 500
City	:	CHARLOTTE
State	:	NC
Zip	:	28202-2012
Country	:	US
Telephone Number	:	704-302-8800
Fax Number	:

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

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	04/12/2022

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