Provider Demographics
NPI:1649362138
Name:FORTKORT, PETER THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:PETER
Middle Name:THOMAS
Last Name:FORTKORT
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 1:300 W 27TH ST
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3075
Mailing Address - Country:US
Mailing Address - Phone:910-671-5220
Mailing Address - Fax:
Practice Address - Street 1:300 W 27TH ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3075
Practice Address - Country:US
Practice Address - Phone:910-671-5220
Practice Address - Fax:910-272-1437
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9500577207R00000X
NC95-00577174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5300138Medicaid
SCN00579Medicaid
NC1649362138Medicaid
NCF89166Medicare UPIN
SCN00579Medicaid
NCNC9871GMedicare PIN
NC2221607FMedicare PIN
NC5300138Medicaid
NCNC9871FMedicare PIN