Provider Demographics
NPI:1275631020
Name:FULLEN, JERYL GLYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:JERYL
Middle Name:GLYNN
Last Name:FULLEN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1101 MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:LOGANSPORT
Mailing Address - State:IN
Mailing Address - Zip Code:46947-1528
Mailing Address - Country:US
Mailing Address - Phone:574-753-1729
Mailing Address - Fax:
Practice Address - Street 1:1101 MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:LOGANSPORT
Practice Address - State:IN
Practice Address - Zip Code:46947-1528
Practice Address - Country:US
Practice Address - Phone:574-753-1729
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-16478207X00000X
IN01063517A207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200993900Medicaid
IN000000696600OtherANTHEM
AR5N934OtherMEDICARE PTAN
KS100118960AMedicaid
KS019741Medicare ID - Type Unspecified
KSB91140Medicare UPIN
KS100118960AMedicaid