MEDICARE: MRS. PAULA L FORTUNE MSPT

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	225100000X	Physical Therapist	05007396A	IN
2	225100000X	Physical Therapist	5501010993	MI

General Provider Information

NPI Number	:	1962903294
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. PAULA L FORTUNE MSPT

Provider Business Mailing Address
First Line	:	9466 FOX RUN
Second Line	:
City	:	BERRIEN CENTER
State	:	MI
Zip	:	49102-8710
Country	:	US
Telephone Number	:	269-473-5655
Fax Number	:	269-473-5555

Provider Business Practice Location Address
First Line	:	423 SYCAMORE ST STE 104
Second Line	:
City	:	NILES
State	:	MI
Zip	:	49120-2374
Country	:	US
Telephone Number	:	269-687-2900
Fax Number	:	269-687-2903

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

Provider Enumeration Date	:	02/22/2018
Last Update Date	:	03/17/2018

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