Provider Demographics
NPI:1609946870
Name:FORTNER, MOLLY (MD)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:FORTNER
Suffix:
Gender:F
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 S COLLEGE ST
Practice Address - Street 2:STE 500
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2012
Practice Address - Country:US
Practice Address - Phone:704-302-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-00046207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00414503OtherRR MEDICARE
NC1609946870Medicaid
SCN0004CMedicaid
NC5905608Medicaid
NC2060282AMedicare PIN
NCP00414503OtherRR MEDICARE
NC1609946870Medicaid
NC5905608Medicaid