Basic Information
Provider Information | |||||||||
NPI: | 1487888061 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | FORT | ||||||||
FirstName: | KEITH | ||||||||
MiddleName: | WESLEY | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3495 PIEDMONT RD NE | ||||||||
Address2: | NINE PIEDMONT CENTER | ||||||||
City: | ATLANTA | ||||||||
State: | GA | ||||||||
PostalCode: | 303051717 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4045045678 | ||||||||
FaxNumber: | 2018620095 | ||||||||
Practice Location | |||||||||
Address1: | 2400 MOUNT ZION PKWY | ||||||||
Address2: | KAISER PERMANENTE SOUTHWOOD MEDICAL CENTER | ||||||||
City: | JONESBORO | ||||||||
State: | GA | ||||||||
PostalCode: | 302362500 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2019439100 | ||||||||
FaxNumber: | 2019437308 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2009 | ||||||||
LastUpdateDate: | 01/10/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 6400 | GA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363AS0400X | 25MP00214500 | NJ | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical | 363A00000X | 006400 | GA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
ID Information
ID | Type | State | Issuer | Description | 162546NMS | 01 | NJ | MEDICARE PTAN | OTHER |