=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902984438
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOSEPH FULLMER MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 01/17/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3601 W 13 MILE RD
-----------------------------------------------------
City | ROYAL OAK
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48073
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-898-9060
-----------------------------------------------------
Fax | 248-898-9054
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 26901 BEAUMONT BLVD SUITE 3D
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48033-3849
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 947-522-1861
-----------------------------------------------------
Fax | 947-522-0307
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207ZN0500X
-----------------------------------------------------
Taxonomy Name | Neuropathology Physician
-----------------------------------------------------
License Number | 271175
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207ZP0101X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology Physician
-----------------------------------------------------
License Number | 54513 - 020
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207ZP0101X
-----------------------------------------------------
Taxonomy Name | Anatomic Pathology Physician
-----------------------------------------------------
License Number | 271175
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------