1013115930 NPI number — STEPHANIE FULLER M.D.

Table of content: STEPHANIE FULLER M.D. (NPI 1013115930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013115930 NPI number — STEPHANIE FULLER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULLER
Provider First Name:
STEPHANIE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013115930
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
100 EAST PENN SQUARE
Provider Second Line Business Mailing Address:
THE WANAMAKER BUILDING 9TH FL
Provider Business Mailing Address City Name:
PHILADELPHIA
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
19107-3323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
267-425-9538
Provider Business Mailing Address Fax Number:
267-425-9552

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
34TH & CIVIC CENTER BLVD
Provider Second Line Business Practice Location Address:
CHILDREN'S HOSPITAL OF PHILADELPHIA
Provider Business Practice Location Address City Name:
PHILADELPHIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
19104-4399
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
215-590-2708
Provider Business Practice Location Address Fax Number:
215-590-2715
Provider Enumeration Date:
07/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  MD420734 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208G00000X , with the licence number: MD420734 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 100743887-0030 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".




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