Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | CHIRO005857 | GA |
N | 111NR0200X | Radiology | 005857 | GA |
N | 213ER0200X | Radiology | 005857 | GA |
N | 111NS0005X | Chiropractic Sports Physician | 005857 | GA |
NPI | 1316001985 |
---|---|
Provider Name | Dr. Troy Reed Fortin |
First Address | Johns Creek, GA 30022-8172 |
Second Address | Johns Creek, GA 30022-8172 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 20/12/2006 |
Last Update Date | 23/08/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
001296 | BCBS (01) | GA |