=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710565643
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON MATTHEW FULLER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2021
-----------------------------------------------------
Last Update Date | 07/27/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 E WOOD ST
-----------------------------------------------------
City | SPARTANBURG
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29303-3040
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-560-6000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3405 CONDUCTOR CIR
-----------------------------------------------------
City | GREER
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29651-4496
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-436-7094
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207P00000X
-----------------------------------------------------
Taxonomy Name | Emergency Medicine Physician
-----------------------------------------------------
License Number | MD91373
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------