MEDICARE: DR. ELISE JAN FULSANG 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	MD23553	OR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1952305385
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELISE JAN FULSANG MD

Provider Business Mailing Address
First Line	:	24800 SE STARK ST.
Second Line	:	SUITE 200
City	:	GRESHAM
State	:	OR
Zip	:	97030
Country	:	US
Telephone Number	:	503-674-1391
Fax Number	:	503-413-1895

Provider Business Practice Location Address
First Line	:	300 N GRAHAM ST
Second Line	:	SUITE 200
City	:	PORTLAND
State	:	OR
Zip	:	97227-1683
Country	:	US
Telephone Number	:	503-413-4134
Fax Number	:	503-413-1895

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

Provider Enumeration Date	:	06/13/2005
Last Update Date	:	04/06/2011

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