Provider Demographics
NPI:1639309206
Name:GEORGE A FOURNIER III MD FACS PA
Entity type:Organization
Organization Name:GEORGE A FOURNIER III MD FACS PA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:A
Authorized Official - Last Name:FOURNIER
Authorized Official - Suffix:III
Authorized Official - Credentials:MD
Authorized Official - Phone:954-492-1177
Mailing Address - Street 1:2466 E COMMERCIAL BLVD
Mailing Address - Street 2:STE 102
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33308-4011
Mailing Address - Country:US
Mailing Address - Phone:954-492-1177
Mailing Address - Fax:954-492-0352
Practice Address - Street 1:2466 E COMMERCIAL BLVD
Practice Address - Street 2:STE 102
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-4011
Practice Address - Country:US
Practice Address - Phone:954-492-1177
Practice Address - Fax:954-492-0352
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GEORGE A FOURNIER III MD FACS PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-17
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME51944332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL0785290001Medicare NSC
FLD21039Medicare UPIN
FLK4331Medicare PIN