Provider Demographics
NPI:1144207382
Name:FORT, THOMAS O (PA)
Entity Type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:O
Last Name:FORT
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:PO BOX 1209
Mailing Address - Street 2:
Mailing Address - City:MURRELLS INLET
Mailing Address - State:SC
Mailing Address - Zip Code:29576-1209
Mailing Address - Country:US
Mailing Address - Phone:843-652-8220
Mailing Address - Fax:843-527-7080
Practice Address - Street 1:701 S MORGAN AVE
Practice Address - Street 2:
Practice Address - City:ANDREWS
Practice Address - State:SC
Practice Address - Zip Code:29510-2959
Practice Address - Country:US
Practice Address - Phone:843-264-5253
Practice Address - Fax:843-264-5970
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC780363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCRHC068Medicaid
P97444Medicare UPIN
SCRHC068Medicaid