=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801848668
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLES SAMUEL FULK
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2006
-----------------------------------------------------
Last Update Date | 01/02/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 E ECONOMY ROAD SUITE 8
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37814-3388
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-587-4600
-----------------------------------------------------
Fax | 423-587-1729
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 400 E ECONOMY RD SUITE 8
-----------------------------------------------------
City | MORRISTOWN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37814-3388
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-587-4600
-----------------------------------------------------
Fax | 423-587-1729
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | MD014379
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------