Provider Demographics
NPI:1518426865
Name:FORTENBERY, GREY WILSON
Entity type:Individual
Prefix:
First Name:GREY
Middle Name:WILSON
Last Name:FORTENBERY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1072 X RAY DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-7488
Mailing Address - Country:US
Mailing Address - Phone:980-399-6330
Mailing Address - Fax:704-671-1095
Practice Address - Street 1:315 19TH ST SE BLDG 100
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-4230
Practice Address - Country:US
Practice Address - Phone:828-328-3500
Practice Address - Fax:828-328-8777
Is Sole Proprietor?:No
Enumeration Date:2019-03-17
Last Update Date:2025-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC202501299208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program