Provider Demographics
NPI:1669443297
Name:FAULL S. TROVER, M.D.,P.C.
Entity Type:Organization
Organization Name:FAULL S. TROVER, M.D.,P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FAULL
Authorized Official - Middle Name:S
Authorized Official - Last Name:TROVER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-787-4122
Mailing Address - Street 1:4155 BAKER ST NE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-1405
Mailing Address - Country:US
Mailing Address - Phone:770-787-4122
Mailing Address - Fax:770-787-4655
Practice Address - Street 1:4155 BAKER ST NE
Practice Address - Street 2:SUITE 300
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-1405
Practice Address - Country:US
Practice Address - Phone:770-787-4122
Practice Address - Fax:770-787-4655
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0427502080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA0007209BMedicaid