Basic Information
| Provider Information | |||||||||
| NPI: | 1255626784 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORTIE | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | J | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 468 | ||||||||
| Address2: | |||||||||
| City: | SKOWHEGAN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049760468 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2078588353 | ||||||||
| FaxNumber: | 2074749261 | ||||||||
| Practice Location | |||||||||
| Address1: | 46 FAIRVIEW AVE | ||||||||
| Address2: | |||||||||
| City: | SKOWHEGAN | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049761481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2074745121 | ||||||||
| FaxNumber: | 2074743441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/13/2011 | ||||||||
| LastUpdateDate: | 12/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | PA286 | ME | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | PA286 | ME | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 12255626784 | 05 | ME | MEDICAID |