MEDICARE: MARK G FULLER 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	207R00000X	Internal Medicine Physician	MD043300L	PA
2	2084P0802X	Addiction Psychiatry Physician	MD043300L	PA
3	2084P0800X	Psychiatry Physician	MD043300L	PA

General Provider Information

NPI Number	:	1659378511
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARK G FULLER MD

Provider Business Mailing Address
First Line	:	1307 FEDERAL ST STE 301
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15212-4769
Country	:	US
Telephone Number	:	412-359-3751
Fax Number	:	412-442-2335

Provider Business Practice Location Address
First Line	:	1307 FEDERAL ST STE 301
Second Line	:
City	:	PITTSBURGH
State	:	PA
Zip	:	15212-4769
Country	:	US
Telephone Number	:	412-359-3751
Fax Number	:	412-442-2335

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

Provider Enumeration Date	:	07/06/2005
Last Update Date	:	09/30/2020

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Directions to “ MARK G FULLER MD” Practice Location

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