Provider Demographics
NPI:1841254166
Name:FORT, SAMUEL L
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:L
Last Name:FORT
Suffix:
Gender:M
Credentials:
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 2145
Mailing Address - Street 2:203 B MOCKSVILLE AVENUE
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28145-2145
Mailing Address - Country:US
Mailing Address - Phone:704-636-0971
Mailing Address - Fax:704-636-8554
Practice Address - Street 1:203B MOCKSVILLE AVE
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-3325
Practice Address - Country:US
Practice Address - Phone:704-636-0971
Practice Address - Fax:704-636-8854
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9501242173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
33148OtherBCBS
NC8933148Medicaid
NC8933148Medicaid
G09190Medicare UPIN