MEDICARE: FAULL SANDERS TROVER 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	208000000X	Pediatrics Physician	042750	GA

General Provider Information

NPI Number	:	1588665624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FAULL SANDERS TROVER M.D.

Provider Business Mailing Address
First Line	:	4155 BAKER ST NE
Second Line	:
City	:	COVINGTON
State	:	GA
Zip	:	30014-1405
Country	:	US
Telephone Number	:	770-787-4122
Fax Number	:	770-787-4655

Provider Business Practice Location Address
First Line	:	4155 BAKER ST NE
Second Line	:
City	:	COVINGTON
State	:	GA
Zip	:	30014-1405
Country	:	US
Telephone Number	:	770-787-4122
Fax Number	:	770-787-4655

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

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	07/08/2007

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