MEDICARE: CENTER FOR ORTHOPEDIC MEDICINE, P.A.

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	2081P2900X	Pain Medicine (Physical Medicine & Rehabilitation) Physician	D5384	TX

General Provider Information

NPI Number	:	1588863278
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTER FOR ORTHOPEDIC MEDICINE, P.A.

Provider Business Mailing Address
First Line	:	223 E 5TH ST
Second Line	:
City	:	TYLER
State	:	TX
Zip	:	75701-4224
Country	:	US
Telephone Number	:	903-526-5000
Fax Number	:	903-526-5006

Provider Business Practice Location Address
First Line	:	11600 JONES RD
Second Line	:	SUITE 108-5
City	:	HOUSTON
State	:	TX
Zip	:	77070-5929
Country	:	US
Telephone Number	:	713-981-1522
Fax Number	:	713-981-9038

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. KENNETH L FULTS
Credential	:	D.O.
Telephone Number	:	903-526-5000

Provider Enumeration Date	:	07/13/2007
Last Update Date	:	07/13/2007

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Directions to “CENTER FOR ORTHOPEDIC MEDICINE, P.A. ” Practice Location

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