Provider Demographics
NPI:1730295551
Name:FULCHER, SIMEON MARCUS (MD)
Entity Type:Individual
Prefix:
First Name:SIMEON
Middle Name:MARCUS
Last Name:FULCHER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:706 SOMERSET WAY
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30909-3131
Mailing Address - Country:US
Mailing Address - Phone:706-737-6603
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:SUITE BP 2109
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0004
Practice Address - Country:US
Practice Address - Phone:706-721-4263
Practice Address - Fax:706-721-6001
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2014-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045795207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00797508AMedicaid
GAG73871Medicare UPIN
GA20BBDMRMedicare ID - Type Unspecified