Provider Demographics
NPI:1154329324
Name:FORTNER, GEORGE S (MD)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:S
Last Name:FORTNER
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 3002
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-0302
Mailing Address - Country:US
Mailing Address - Phone:360-414-2048
Mailing Address - Fax:360-575-6749
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2310
Practice Address - Country:US
Practice Address - Phone:360-501-3500
Practice Address - Fax:360-501-3555
Is Sole Proprietor?:No
Enumeration Date:2005-07-12
Last Update Date:2007-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000169062086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8395006Medicaid
WA8943476OtherCRIME VICTIMS
OR160747Medicaid
WA0217049OtherLABOR & IND.
OR160747Medicaid
WA8863986Medicare PIN