Provider Demographics
NPI:1497824262
Name:SUSAN L FULLEMANN MD
Entity Type:Organization
Organization Name:SUSAN L FULLEMANN MD
Other - Org Name:BURLINGAME FAMILY HEALTH MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:FULLEMANN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:650-697-7202
Mailing Address - Street 1:1820 OGDEN DR
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-5384
Mailing Address - Country:US
Mailing Address - Phone:650-697-7202
Mailing Address - Fax:650-697-7059
Practice Address - Street 1:1820 OGDEN DR
Practice Address - Street 2:1ST FLOOR
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-5384
Practice Address - Country:US
Practice Address - Phone:650-697-7202
Practice Address - Fax:650-697-7059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-07
Last Update Date:2012-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG51875174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty