Healthcare Provider Details

I. General information

NPI: 1013115930
Provider Name (Legal Business Name): STEPHANIE FULLER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34TH & CIVIC CENTER BLVD CHILDREN'S HOSPITAL OF PHILADELPHIA
PHILADELPHIA PA
19104-4399
US

IV. Provider business mailing address

6201 GREENLEIGH AVE
MIDDLE RIVER MD
21220-2004
US

V. Phone/Fax

Practice location:
  • Phone: 215-590-2708
  • Fax: 215-590-2715
Mailing address:
  • Phone: 410-955-5000
  • Fax: 410-500-4266

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberD0105511
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberMD420734
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code208G00000X
TaxonomyThoracic Surgery (Cardiothoracic Vascular Surgery) Physician
License NumberMD420734
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: