Basic Information
| Provider Information | |||||||||
| NPI: | 1043636202 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FORTNER | ||||||||
| FirstName: | GRADY | ||||||||
| MiddleName: | AUSBUR | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 25578 | ||||||||
| Address2: | |||||||||
| City: | BARRIGADA | ||||||||
| State: | GU | ||||||||
| PostalCode: | 969215578 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6714807934 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 554 KEILY STREET | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7579537550 | ||||||||
| FaxNumber: | 7579537560 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2014 | ||||||||
| LastUpdateDate: | 12/17/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/17/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207P00000X | 0116027243 | VA | N | Allopathic & Osteopathic Physicians | Emergency Medicine | 207P00000X | M-2191 | GU | Y | Allopathic & Osteopathic Physicians | Emergency Medicine |
No ID Information.