Provider Demographics
NPI:1376655217
Name:FORTUNA FAMILY MEDICAL GROUP INC
Entity Type:Organization
Organization Name:FORTUNA FAMILY MEDICAL GROUP INC
Other - Org Name:OLSON GOBLE & JUTILA INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:JUTILA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-725-3334
Mailing Address - Street 1:874 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-1926
Mailing Address - Country:US
Mailing Address - Phone:707-725-3334
Mailing Address - Fax:707-725-2455
Practice Address - Street 1:874 MAIN ST
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-1926
Practice Address - Country:US
Practice Address - Phone:707-725-3334
Practice Address - Fax:707-725-2455
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0021870Medicaid
RHM03936FOtherRURAL HEALTH MEDICAL
CA053936Medicare Oscar/Certification
RHM03936FOtherRURAL HEALTH MEDICAL