Provider Demographics
NPI:1164567830
Name:FULLERTON MEDICAL CLINIC, PLLC
Entity Type:Organization
Organization Name:FULLERTON MEDICAL CLINIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:C
Authorized Official - Last Name:FULLERTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:615-284-7900
Mailing Address - Street 1:2021 CHURCH ST
Mailing Address - Street 2:SUITE 504
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-2021
Mailing Address - Country:US
Mailing Address - Phone:615-284-7900
Mailing Address - Fax:615-284-3488
Practice Address - Street 1:2021 CHURCH ST
Practice Address - Street 2:SUITE 504
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37203-2021
Practice Address - Country:US
Practice Address - Phone:615-284-7900
Practice Address - Fax:615-284-3488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNB59030Medicare UPIN