Provider Demographics
NPI:1558322818
Name:FORTUNE, JAMES ALBERT (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:ALBERT
Last Name:FORTUNE
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 1:20225 E 9 MILE RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1775
Mailing Address - Country:US
Mailing Address - Phone:596-779-8700
Mailing Address - Fax:586-498-1425
Practice Address - Street 1:20225 E 9 MILE RD
Practice Address - Street 2:SUITE A
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1775
Practice Address - Country:US
Practice Address - Phone:596-779-8700
Practice Address - Fax:586-498-1425
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043464207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2121462Medicaid
MI2121462Medicaid
MIMI3971Medicare PIN
0N0170Medicare ID - Type Unspecified