1255561775 NPI number — MATTHEW FULTON

Table of content: MATTHEW FULTON (NPI 1255561775)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255561775 NPI number — MATTHEW FULTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FULTON
Provider First Name:
MATTHEW
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
M

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:
1255561775
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2000 JOSEPH E SANKER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CINCINNATI
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45212-1979
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
513-841-7400
Provider Business Mailing Address Fax Number:
513-841-7402

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3301 MERCY HEALTH BLVD
Provider Second Line Business Practice Location Address:
SUITE 525
Provider Business Practice Location Address City Name:
CINCINNATI
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45211-1118
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
513-841-7700
Provider Business Practice Location Address Fax Number:
513-841-7701
Provider Enumeration Date:
07/17/2009

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:  4301094972 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208800000X , with the licence number: 35125792 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: CC2433 . This is a "MEDICARE RR" identifier , issued by the state of ( OH ) . This identifiers is of the category "OTHER".




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