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General NPI Number Information
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NPI Number | 1518941707
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Entity Type | Organization
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Legal Business Name | DRS FULLIN MANDA KREAGER & ABBO LLC
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Dates
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Enumeration Date | 12/01/2005
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Last Update Date | 10/24/2007
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Provider Practice Location Address
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Address Line | 6308 8TH AVE STE 3060
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City | KENOSHA
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State | WI
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Zip | 53143-5082
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Country | US
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Telephone | 262-656-8271
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Fax | 262-656-8255
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Provider Business Mailing Address
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Address Line | 6308 8TH AVE STE 3060
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City | KENOSHA
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State | WI
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Zip | 53143-5082
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Country | US
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Telephone | 262-656-8271
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Fax | 262-656-8255
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. KEVIN J FULLIN
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Credential | MD FACC
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Telephone | 262-656-8271
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207RC0000X
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Taxonomy Name | Cardiovascular Disease Physician
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License Number |
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License Number State | WI
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