1003072158 NPI number — MR. JAMES MITCHELL FORTNER MHPP

Table of content: MR. JAMES MITCHELL FORTNER MHPP (NPI 1003072158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1003072158 NPI number — MR. JAMES MITCHELL FORTNER MHPP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORTNER
Provider First Name:
JAMES
Provider Middle Name:
MITCHELL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MHPP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1003072158
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/29/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 180
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PARON
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72122-0180
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
501-594-5200
Provider Business Mailing Address Fax Number:
501-594-5244

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
525 WISTERIA DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORTH LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72118-3567
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-594-5200
Provider Business Practice Location Address Fax Number:
501-594-5244
Provider Enumeration Date:
07/29/2008

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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