Provider Demographics
NPI:1932191319
Name:FORT, PETER LAWRENCE (MD)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:LAWRENCE
Last Name:FORT
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 1:777 HOSPITAL WAY # 202
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5175
Mailing Address - Country:US
Mailing Address - Phone:208-239-2640
Mailing Address - Fax:
Practice Address - Street 1:35 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:BLAIRSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30512-3139
Practice Address - Country:US
Practice Address - Phone:706-745-2111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY8823A207RP1001X
NV16668207RP1001X
GA90203207RP1001X, 207RS0012X
IDM-13839207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00003518OtherMEDICARE RR
FL259252500Medicaid
FL49343OtherBCBS
FL259252500Medicaid
FL259252500Medicaid
FL259252500Medicaid