Provider Demographics
NPI:1548557317
Name:BRIAN FULLER MD PC
Entity Type:Organization
Organization Name:BRIAN FULLER MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:303-355-3700
Mailing Address - Street 1:2373 CENTRAL PARK BLVD
Mailing Address - Street 2:SUITE 303
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80238-2300
Mailing Address - Country:US
Mailing Address - Phone:303-355-3700
Mailing Address - Fax:
Practice Address - Street 1:2373 CENTRAL PARK BLVD
Practice Address - Street 2:SUITE 303
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80238-2300
Practice Address - Country:US
Practice Address - Phone:303-355-3700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRIAN FULLER, MD, PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-06-30
Last Update Date:2012-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCOA101399Medicare PIN