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General NPI Number Information
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NPI Number | 1053408864
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Entity Type | Individual
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Provider Name | MICHAEL PAUL FULLENKAMP M.D.
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Gender | Male
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Dates
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Enumeration Date | 10/05/2006
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Last Update Date | 09/08/2009
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Provider Practice Location Address
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Address Line | 1 BARNES JEWISH HOSPITAL PLAZA
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City | ST. LOUIS
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State | MO
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Zip | 63110
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Country | US
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Telephone | 314-294-0446
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Fax |
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Provider Business Mailing Address
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Address Line | 379 N TAYLOR AVE APT 1W
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City | SAINT LOUIS
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State | MO
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Zip | 63108-1981
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207P00000X
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Taxonomy Name | Emergency Medicine Physician
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License Number | 2005015807
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License Number State | MO
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