Basic Information
| Provider Information | |||||||||
| NPI: | 1619119252 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | FORTUN | ||||||||
| FirstName: | CHAD | ||||||||
| MiddleName: | MICHAEL | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | M D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1717 SHIPYARD BLVD STE 350 | ||||||||
| Address2: | CAROLINA SPORTS MEDICINE | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28403 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107990110 | ||||||||
| FaxNumber: | 9107991958 | ||||||||
| Practice Location | |||||||||
| Address1: | 1202 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103413300 | ||||||||
| FaxNumber: | 9102512067 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2009 | ||||||||
| LastUpdateDate: | 01/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207XX0005X | 2015-01168 | NC | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | 2015-01168 | NC | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
No ID Information.