Provider Demographics
NPI:1225068455
Name:FULTON FAMILY HEALTH ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:FULTON FAMILY HEALTH ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JAIME
Authorized Official - Middle Name:
Authorized Official - Last Name:MOTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-642-1990
Mailing Address - Street 1:2613 FAIRWAY DR
Mailing Address - Street 2:SUITE C
Mailing Address - City:FULTON
Mailing Address - State:MO
Mailing Address - Zip Code:65251-3936
Mailing Address - Country:US
Mailing Address - Phone:573-642-1990
Mailing Address - Fax:573-642-1866
Practice Address - Street 1:2613 FAIRWAY DR
Practice Address - Street 2:SUITE C
Practice Address - City:FULTON
Practice Address - State:MO
Practice Address - Zip Code:65251-3936
Practice Address - Country:US
Practice Address - Phone:573-642-1990
Practice Address - Fax:573-642-1866
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO504746603Medicaid
MO000013048Medicare PIN