Healthcare Provider Details

I. General information

NPI: 1033409438
Provider Name (Legal Business Name): BRIAN EDWARD FULLER M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2011
Last Update Date: 05/22/2020
Certification Date: 05/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6107 PINEWOOD RD
NUNNELLY TN
37137-2523
US

IV. Provider business mailing address

30 BURTON HILLS BLVD SUITE 375
NASHVILLE TN
37215-6140
US

V. Phone/Fax

Practice location:
  • Phone: 888-852-6672
  • Fax: 305-891-4228
Mailing address:
  • Phone: 615-327-4877
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD51960
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License NumberMD51960
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: