Provider Demographics
NPI:1710982673
Name:FULTON, MICHAEL G (P T)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:G
Last Name:FULTON
Suffix:
Gender:M
Credentials:P T
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2304 JACKSON AVE W
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:MS
Mailing Address - Zip Code:38655-5416
Mailing Address - Country:US
Mailing Address - Phone:662-234-8559
Mailing Address - Fax:662-234-7923
Practice Address - Street 1:2170 S LAMAR BLVD
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5224
Practice Address - Country:US
Practice Address - Phone:662-234-8559
Practice Address - Fax:662-234-7923
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT1336225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS650021553OtherMEDICARE RAILROAD
AL51511964Medicaid
AL51511964OtherBCBS OF AL
MS00120446Medicaid
MS650021553OtherMEDICARE RAILROAD
MS00120446Medicaid