Provider Demographics
NPI:1215960224
Name:FRAZIER T FORTENBERRY JR MD PLC
Entity type:Organization
Organization Name:FRAZIER T FORTENBERRY JR MD PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRAZIER
Authorized Official - Middle Name:T
Authorized Official - Last Name:FORTENBERRY
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:434-244-5722
Mailing Address - Street 1:630 PETER JEFFERSON PKWY
Mailing Address - Street 2:SUITE 135
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-8605
Mailing Address - Country:US
Mailing Address - Phone:434-244-5722
Mailing Address - Fax:434-244-5723
Practice Address - Street 1:630 PETER JEFFERSON PKWY
Practice Address - Street 2:SUITE 135
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911-8605
Practice Address - Country:US
Practice Address - Phone:434-244-5722
Practice Address - Fax:434-244-5723
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-10
Last Update Date:2011-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208800000XAllopathic & Osteopathic PhysiciansUrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VADA1531OtherMEDICARE PIN
VADA1531OtherMEDICARE PIN