MEDICARE: TAMA FULLER

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	208000000X	Pediatrics Physician	021981	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	4303744	OTHER	AETNA CAPITATED
2	550624	OTHER	AETNA
3	158759	OTHER	BLUE CROSS BLUE SHIELD
4	691301	OTHER	CIGNA HEALTHCARE
5	40467	OTHER	GREAT WEST

General Provider Information

NPI Number	:	1386609477
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAMA FULLER

Provider Business Mailing Address
First Line	:	1100 LAKE HEARN DR NE
Second Line	:	SUITE 100
City	:	ATLANTA
State	:	GA
Zip	:	30342-1523
Country	:	US
Telephone Number	:	404-256-3178
Fax Number	:	404-256-3583

Provider Business Practice Location Address
First Line	:	1100 LAKE HEARN DR NE
Second Line	:	SUITE 100
City	:	ATLANTA
State	:	GA
Zip	:	30342-1523
Country	:	US
Telephone Number	:	404-256-3178
Fax Number	:	404-256-3583

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

Provider Enumeration Date	:	04/20/2006
Last Update Date	:	07/08/2007

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Directions to “ TAMA FULLER ” Practice Location

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