MEDICARE: ELIZA ERVIN FULTON THORNTON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	MT188666	PA
2	207QA0505X	Adult Medicine Physician	MD436674	PA
3	207Q00000X	Family Medicine Physician	MD436674	PA

General Provider Information

NPI Number	:	1255582201
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZA ERVIN FULTON THORNTON MD

Provider Business Mailing Address
First Line	:	500 KIRTS BLVD STE 100
Second Line	:
City	:	TROY
State	:	MI
Zip	:	48084-4135
Country	:	US
Telephone Number	:	248-434-6169
Fax Number	:	855-618-6655

Provider Business Practice Location Address
First Line	:	1055 WESTLAKES DR STE 3152
Second Line	:
City	:	BERWYN
State	:	PA
Zip	:	19312-2410
Country	:	US
Telephone Number	:	215-346-6050
Fax Number	:	215-220-3562

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/08/2008
Last Update Date	:	11/23/2020

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