Healthcare Provider Details

I. General information

NPI: 1396781944
Provider Name (Legal Business Name): GREGG S FULMER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2006
Last Update Date: 05/18/2022
Certification Date: 05/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 PALMER AVE.
BELLEFONTAINE OH
43311-2281
US

IV. Provider business mailing address

205 E PALMER RD
BELLEFONTAINE OH
43311-2281
US

V. Phone/Fax

Practice location:
  • Phone: 937-592-4015
  • Fax:
Mailing address:
  • Phone: 937-593-0245
  • Fax: 937-592-8633

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number35.081568
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35081568
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: