Keith Wesley Fort, PA-C

Primary specialty

Physician AssistantTaxonomy code 363A00000X

License

006400 Issued in GA

Practice address

2400 Mount Zion Pkwy
Kaiser Permanente Southwood Medical Center
Jonesboro, GA 30236-2500

Phone

(201) 943-9100

Fax

(201) 943-7308

NPI assigned

May 11, 2009

Sex

Male

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 3

Addresses

Other identifiers 1

Electronic endpoints 1

Medicare fee-for-service enrollment

Enrolled in GA

Eligible to order & refer

• Part B services: Yes
• Medical equipment: Yes
• Home health: Yes
• Power mobility devices: Yes
• Hospice: No

Green means eligible to order or refer.

Enrollment records 1

Specialty

Physician Assistant

Education

Other, 2008

Medicare assignment

Accepts the Medicare-approved amount as payment in full

Group practices

The Southeast Permanente Medical GroupGroup PAC ID 6204829013, 823 clinicians

Physiotherapy Associates IncGroup PAC ID 3577470442, shared by 50 NPIs, 1,432 clinicians

Practice addresses (Care Compare)

Medicare enrollment (NPD)

Enrolled

Credentials

Physician Assistant

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

• The Southeast Permanente Medical Group

  • Internal Medicine Physician
  • Atlanta, GA
  • NPI 1245266956
  Medicare reassignment Care Compare group
• Lagrange Emergency Physicians, LLC

  • Emergency Medicine Physician
  • Lagrange, GA
  • NPI 1760437560
  Medicare reassignment
• Piedmont Ed Professionals, LLC

  • Emergency Medicine Physician
  • Atlanta, GA
  • NPI 1932477429
  Medicare reassignment
• The Bortolazzo Group, LLC

  • Emergency Medicine Physician
  • Austell, GA
  • NPI 1801965082
  Medicare reassignment
• Hand & Trauma Institute

  • Surgery of the Hand (Surgery) Physician
  • Cliffside Park, NJ
  • NPI 1053581074
  NPD (past)

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1242000000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1641772800000",
    "number": "1487888061",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "3495 PIEDMONT RD NE",
            "address_2": "NINE PIEDMONT CENTER",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303051717",
            "telephone_number": "404-504-5678",
            "fax_number": "201-862-0095"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2400 MOUNT ZION PKWY",
            "address_2": "KAISER PERMANENTE SOUTHWOOD MEDICAL CENTER",
            "city": "JONESBORO",
            "state": "GA",
            "postal_code": "302362500",
            "telephone_number": "201-943-9100",
            "fax_number": "201-943-7308"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "FORT",
        "first_name": "KEITH",
        "middle_name": "WESLEY",
        "name_prefix": "Mr.",
        "credential": "PA-C",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2009-05-11",
        "last_updated": "2022-01-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "GA",
            "license": "6400",
            "primary": false
        },
        {
            "code": "363AS0400X",
            "taxonomy_group": "",
            "desc": "Physician Assistant, Surgical",
            "state": "NJ",
            "license": "25MP00214500",
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "GA",
            "license": "006400",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "MEDICARE PTAN",
            "identifier": "162546NMS",
            "state": "NJ"
        }
    ],
    "endpoints": [
        {
            "endpointType": "SOAP",
            "endpointTypeDescription": "SOAP URL",
            "endpoint": "https://careepiceast.kp.org:14430/Interconnect-prodgam/wcf/epic.community.hie/xcpdrespondinggatewaysync.svc/ceq",
            "affiliation": "Y",
            "endpointDescription": "Carequality",
            "affiliationName": "Permanente Medical Group",
            "use": "HIE",
            "useDescription": "Health Information Exchange (HIE)",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "C-CDA",
            "address_1": "3650 Steve Reynolds Blvd",
            "city": "Duluth",
            "state": "GA",
            "country_code": "US",
            "postal_code": "300964506",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

• Linda Foltz, PH.D.
• Dorothy A. Fondi, MS, LPC, CPCS, MAC
• Fedia Eveline Fontaine
• Katia Antonine Forbin, MD
• Olivia Forrestel, FNP-C
• Priscilla Tate Foster, CNA
• Fountain of Life Healthcare Agency LLC
• Elaine Karen Franzetti, LCSW
• Freedom Now Home Care
• August Freeman

• Physician Assistant in Jonesboro, GA
• Providers in Jonesboro, GA by specialty
• Physician Assistant in Georgia

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 10, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments; Order and Referring.
• Medicare Care Compare (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.