Healthcare Provider Details

I. General information

NPI: 1972731370
Provider Name (Legal Business Name): RENEE CHRISTINE FULLER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: RENEE CHRISTINE RADER

II. Dates (important events)

Enumeration Date: 06/24/2009
Last Update Date: 10/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 QUARTER ST
GLADWIN MI
48624-1941
US

IV. Provider business mailing address

609 QUARTER ST
GLADWIN MI
48624-1941
US

V. Phone/Fax

Practice location:
  • Phone: 989-246-6371
  • Fax: 989-246-6330
Mailing address:
  • Phone: 989-246-6371
  • Fax: 989-246-6330

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301094316
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number45676
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: