Provider Demographics
NPI:1417947714
Name:FORTNEY, SIDNEY RAY (MD)
Entity Type:Individual
Prefix:
First Name:SIDNEY
Middle Name:RAY
Last Name:FORTNEY
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 1:8715 E OAK ISLAND DR
Mailing Address - Street 2:
Mailing Address - City:OAK ISLAND
Mailing Address - State:NC
Mailing Address - Zip Code:28465-8367
Mailing Address - Country:US
Mailing Address - Phone:910-278-3316
Mailing Address - Fax:910-278-1415
Practice Address - Street 1:8715 E OAK ISLAND DR
Practice Address - Street 2:
Practice Address - City:OAK ISLAND
Practice Address - State:NC
Practice Address - Zip Code:28465-8367
Practice Address - Country:US
Practice Address - Phone:910-278-3316
Practice Address - Fax:910-278-1415
Is Sole Proprietor?:No
Enumeration Date:2005-10-27
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC13798207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8933170Medicaid
NCP00399761OtherRR MEDICARE
NC33170OtherBCBS IND PROV #
NCP00399761OtherRR MEDICARE
NCD33117Medicare UPIN