Provider Demographics
NPI:1295707487
Name:FORTIN, GREGORY J (MD)
Entity type:Individual
Prefix:
First Name:GREGORY
Middle Name:J
Last Name:FORTIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5020 W BRISTOL RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-2919
Mailing Address - Country:US
Mailing Address - Phone:810-732-1620
Mailing Address - Fax:810-732-8559
Practice Address - Street 1:5020 W BRISTOL RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-2919
Practice Address - Country:US
Practice Address - Phone:810-732-1620
Practice Address - Fax:810-732-8559
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIGF0483902086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0210222032OtherHEALTHPLUS OF MICHIGAN
MI204107OtherMCLAREN HEALTH PLAN/ADVAN
MIB63761OtherHEALTH ALLIANCE PLAN
MI382237803112OtherCOMMUNITY CHOICE
MI4294605OtherAETNA
MI105381OtherPREFERRED CHOICE PPO
MI105381OtherCARE CHOICE HMO
ME109241OtherGREAT LAKES HEALTH PLAN
MI2607980Medicaid
MI0202532841OtherBC/BS OF MICHIGAN
MIC1986OtherM-CARE
MI0202532841OtherBC/BS OF MICHIGAN
MI204107OtherMCLAREN HEALTH PLAN/ADVAN