Basic Information
| Provider Information | |||||||||
| NPI: | 1861538951 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORTUNE | ||||||||
| FirstName: | JAMES | ||||||||
| MiddleName: | EVERETT | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 847 | ||||||||
| Address2: | |||||||||
| City: | CORDOVA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380880847 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9018210338 | ||||||||
| FaxNumber: | 9015078292 | ||||||||
| Practice Location | |||||||||
| Address1: | 7580 CLARINGTON CV | ||||||||
| Address2: | |||||||||
| City: | SOUTHAVEN | ||||||||
| State: | MS | ||||||||
| PostalCode: | 386715657 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6623491940 | ||||||||
| FaxNumber: | 6623493212 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2007 | ||||||||
| LastUpdateDate: | 01/28/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | MD0000007792 | TN | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 06635 | MS | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00017199 | 05 | MS | MEDICAID |