Provider Demographics
NPI:1518941707
Name:DRS FULLIN MANDA KREAGER & ABBO LLC
Entity Type:Organization
Organization Name:DRS FULLIN MANDA KREAGER & ABBO LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:J
Authorized Official - Last Name:FULLIN
Authorized Official - Suffix:
Authorized Official - Credentials:MD FACC
Authorized Official - Phone:262-656-8271
Mailing Address - Street 1:6308 8TH AVE
Mailing Address - Street 2:STE 3060
Mailing Address - City:KENOSHA
Mailing Address - State:WI
Mailing Address - Zip Code:53143-5082
Mailing Address - Country:US
Mailing Address - Phone:262-656-8271
Mailing Address - Fax:262-656-8255
Practice Address - Street 1:6308 8TH AVE
Practice Address - Street 2:STE 3060
Practice Address - City:KENOSHA
Practice Address - State:WI
Practice Address - Zip Code:53143-5082
Practice Address - Country:US
Practice Address - Phone:262-656-8271
Practice Address - Fax:262-656-8255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-01
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty