Provider Demographics
NPI:1073596789
Name:FORTENBERY, EDWIN J (MD)
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:J
Last Name:FORTENBERY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1828
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31702-1828
Mailing Address - Country:US
Mailing Address - Phone:706-653-1088
Mailing Address - Fax:706-653-1162
Practice Address - Street 1:417 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-1943
Practice Address - Country:US
Practice Address - Phone:706-653-1088
Practice Address - Fax:706-653-1162
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0452212085R0202X, 2085R0204X, 2085N0700X, 2085P0229X, 2085N0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Not Answered2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Not Answered2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Not Answered2085P0229XAllopathic & Osteopathic PhysiciansRadiologyPediatric Radiology
Not Answered2085N0904XAllopathic & Osteopathic PhysiciansRadiologyNuclear Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GABCBSOther52584721 013
GABCBSOther52584721 013
GA30BDMJPMedicare ID - Type Unspecified