Provider Demographics
NPI:1083770408
Name:FULCHER, THOMAS BRIAN (DC)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:BRIAN
Last Name:FULCHER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:331 N GRAND AVE W
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62702-2518
Mailing Address - Country:US
Mailing Address - Phone:217-544-3922
Mailing Address - Fax:217-233-5082
Practice Address - Street 1:331 N GRAND AVE W
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62702-2518
Practice Address - Country:US
Practice Address - Phone:217-544-3922
Practice Address - Fax:217-233-5082
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL195704OtherHEALTHLINK
IL182011OtherBLUE CROSS BLUE SHIELD
ILT31254Medicare UPIN
IL182011OtherBLUE CROSS BLUE SHIELD