Healthcare Provider Details

I. General information

NPI: 1053408864
Provider Name (Legal Business Name): MICHAEL PAUL FULLENKAMP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/05/2006
Last Update Date: 09/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 BARNES JEWISH HOSPITAL PLAZA
ST. LOUIS MO
63110
US

IV. Provider business mailing address

379 N TAYLOR AVE APT 1W
SAINT LOUIS MO
63108-1981
US

V. Phone/Fax

Practice location:
  • Phone: 314-294-0446
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number2005015807
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: