Provider Demographics
NPI:1114900024
Name:FORT, GLENN G (MD)
Entity Type:Individual
Prefix:
First Name:GLENN
Middle Name:G
Last Name:FORT
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 1:115 CASS AVE
Mailing Address - Street 2:LANDMARK MEDICAL CENTER
Mailing Address - City:WOONSOCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02895
Mailing Address - Country:US
Mailing Address - Phone:401-766-3428
Mailing Address - Fax:401-767-1633
Practice Address - Street 1:115 CASS AVE
Practice Address - Street 2:LANDMARK MEDICAL CENTER
Practice Address - City:WOONSOCKET
Practice Address - State:RI
Practice Address - Zip Code:02895
Practice Address - Country:US
Practice Address - Phone:401-766-3428
Practice Address - Fax:401-767-1633
Is Sole Proprietor?:No
Enumeration Date:2005-11-23
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD07281207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI9006604Medicaid
RI9006604Medicaid
RIE02126Medicare UPIN