Provider Demographics
NPI:1457011314
Name:FORTNER SURGICAL ASSISTING P.C.
Entity Type:Organization
Organization Name:FORTNER SURGICAL ASSISTING P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:MACY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:FORTNER
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:770-533-3398
Mailing Address - Street 1:25 HEMLOCK SHOALS DR
Mailing Address - Street 2:
Mailing Address - City:DAWSONVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30534-0043
Mailing Address - Country:US
Mailing Address - Phone:770-533-3398
Mailing Address - Fax:
Practice Address - Street 1:25 HEMLOCK SHOALS DR
Practice Address - Street 2:
Practice Address - City:DAWSONVILLE
Practice Address - State:GA
Practice Address - Zip Code:30534-0043
Practice Address - Country:US
Practice Address - Phone:770-533-3398
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-20
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1154950905Medicaid