MEDICARE: DR. GREGORY MICHAEL FULLER M.D.

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	H8646	TX

General Provider Information

NPI Number	:	1356347306
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GREGORY MICHAEL FULLER M.D.

Provider Business Mailing Address
First Line	:	4351 BOOTH CALLOWAY RD
Second Line	:	SUITE 101
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-7378
Country	:	US
Telephone Number	:	817-284-1165
Fax Number	:	817-284-4990

Provider Business Practice Location Address
First Line	:	300 NORTH RUFE SNOW DR
Second Line	:
City	:	KELLER
State	:	TX
Zip	:	76248
Country	:	US
Telephone Number	:	817-431-3800
Fax Number	:	817-337-0784

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

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	07/20/2010

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