Provider Demographics
NPI:1871595512
Name:FORTNER, MICHAEL SCOTT (CRNA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
Last Name:FORTNER
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 771522
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38177-1522
Mailing Address - Country:US
Mailing Address - Phone:901-249-7668
Mailing Address - Fax:901-261-2542
Practice Address - Street 1:1601 NEW CASTLE RD
Practice Address - Street 2:
Practice Address - City:FORREST CITY
Practice Address - State:AR
Practice Address - Zip Code:72335-2218
Practice Address - Country:US
Practice Address - Phone:870-261-0513
Practice Address - Fax:901-261-2542
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR105201163W00000X
ARC002946367500000X, 367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR1871595512OtherWELLCARE - MEDICARE
AR196069001Medicaid
AR1871595512OtherUNITED HEALTHCARE
TN4245152OtherBLUE CROSS BLUE SHIELD TENNESSEE
AR1871595512OtherTRICARE - SOUTH REGION
AR1871595512OtherBAPTIST HEALTH SERVICES GROUP, INC.
AR1871595512OtherQUALCHOICE OF ARKANSAS
AR1871595512OtherARKANSAS BLUE CROSS BLUE SHIELD
TNP00820226OtherRR MEDICARE-PALMETTO GBA
AR1871595512OtherQUALCHOICE OF ARKANSAS
AR1871595512OtherQUALCHOICE OF ARKANSAS
AR1871595512OtherARKANSAS BLUE CROSS BLUE SHIELD