Individual
MICHAEL SCOTT FORTNER
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CRNA
Contact information
Practice address
1601 NEW CASTLE RD, FORREST CITY, AR 72335-2218
(870) 261-0513
(901) 261-2542
Mailing address
PO BOX 771522, MEMPHIS, TN 38177-1522
(901) 249-7668
(901) 261-2542
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
R105201
AR
367500000X
Certified Registered Nurse Anesthetist
Primary
C002946
AR
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1871595512
WELLCARE - MEDICARE
AR
05
—
196069001
—
AR
01
—
4245152
BLUE CROSS BLUE SHIELD TENNESSEE
TN
01
—
P00820226
RR MEDICARE-PALMETTO GBA
TN
Enumeration date
08/12/2005
Last updated
12/02/2019
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