MEDICARE: FORTNER MEDICAL CLINIC, LLC

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	:	1710350863
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FORTNER MEDICAL CLINIC, LLC

Provider Business Mailing Address
First Line	:	222 S 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	:	222 S 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	:	CEO
Name	:	GREGORY L FORTNER
Credential	:	MD
Telephone Number	:	912-394-1002

Provider Enumeration Date	:	11/10/2015
Last Update Date	:	11/10/2015

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