MEDICARE: MARY JANE FULLWOOD 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	207Q00000X	Family Medicine Physician	56645	TN

General Provider Information

NPI Number	:	1306208954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY JANE FULLWOOD MD

Provider Business Mailing Address
First Line	:	832 MULBERRY AVE
Second Line	:
City	:	SELMER
State	:	TN
Zip	:	38375-2334
Country	:	US
Telephone Number	:	731-434-0200
Fax Number	:	731-434-0203

Provider Business Practice Location Address
First Line	:	832 MULBERRY AVE
Second Line	:
City	:	SELMER
State	:	TN
Zip	:	38375-2334
Country	:	US
Telephone Number	:	731-434-0200
Fax Number	:	731-434-0203

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

Provider Enumeration Date	:	03/23/2016
Last Update Date	:	12/22/2023

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