1659609923 NPI number — MR. CARROL SHANE FORTENBERRY P.T.

Table of content: MR. CARROL SHANE FORTENBERRY P.T. (NPI 1659609923)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1659609923 NPI number — MR. CARROL SHANE FORTENBERRY P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FORTENBERRY
Provider First Name:
CARROL
Provider Middle Name:
SHANE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
P.T.
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:
1659609923
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2844 TRACELAND DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TUPELO
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
38801-4200
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
188-863-9692
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2844 TRACELAND AVE.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TUPELO
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
188-863-9692
Provider Business Practice Location Address Fax Number:
662-680-5097
Provider Enumeration Date:
11/25/2009

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: 225100000X , with the licence number:  PT0345 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 225100000X , with the licence number: PT0000008246 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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





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